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

 
We decided that the Plan does not have to pre-approve inpatient level of care for approved knee surgery. 
 
You asked the Plan to pre-approve inpatient level of care for approved knee surgery. You say that the requested 
inpatient level of care for approved knee surgery is medically necessary. The Plan denied your request. The 
Plan says the requested inpatient level of care for approved knee surgery 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 inpatient level of care for approved 
knee surgery. Our reviewer says that the requested inpatient level of care for approved knee surgery is not 
medically necessary. Our physician reviewer found the enrollee was approved total knee arthroplasty. The 
approved surgery can safely be performed under an observational level of care. There is no need for an 
inpatient level of care based on the records provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient level of care for approved knee surgery have not been met. Therefore, 
we decided that the Plan does not have to pre-approve inpatient level of care for approved knee surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nervous system procedure (64999) provided. 
 
You asked the Plan to pay for a nervous system procedure. You say that there is not a CPT code for the service 
performed. The Plan denied your request. The Plan says this is not an appropriate code for the service 
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 64999 is unlisted procedure, nervous system. 
 
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 a nervous system procedure. Our reviewer 
says that the use of this code is not supported. Our physician reviewer found he enrollee received a peripheral 
nerve block, with ultrasound guidance, behind his knee.  There are codes for peripheral nerve injection, which 
are more appropriate than the billed code for an unlisted nervous system procedure.  As such, the billing of 
CPT 64999 is not appropriate. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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 nervous system procedure have not been met. Therefore, we decided that the 
Plan does not have to pay for a nervous system procedure (64999) provided.
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 it is felt IRF care would be best for the enrollee's 
recovery. The Plan denied your request. The Plan says the enrollee does not need this level of care. 
 
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 the enrollee was admitted to the hospital on October 29, 2020, after a falling causing 
a hip fracture. The enrollee does not require the intensity of services provided at an IRF. Specifically, the 
enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician 
evaluation. The enrollee's care needs can be met at a lower level of care. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for full mouth scaling (D4346) provided on June 29, 2020. 
 
You asked the Plan to pay for full mouth scaling (D4346). You say that insurance will cover 3 procedures per 
year. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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 pay for full 
mouth scaling (D4346) provided on June 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office outpatient visit (99214) and presumptive drug test 
(80307) provided on February 26, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for office visit and drug test. You say that the services rendered were medically 
necessary. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent 
services rendered by an out-of-network provider. 
 
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 office outpatient visit (99214) and presumptive 
drug test (80307) provided on February 26, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on June 24, 2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
the Plan requires utilization of network providers when possible and available, and requires authorization for 
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for subsequent nursing facility care provided on June 24, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the cardiovascular genetic panel provided on April 28, 2020. 
 
You asked the Plan to pay for the genetic panel. You say that this testing was medically necessary and should 
be covered. The Plan denied your request. The Plan says that this is not coded correctly as the rules state that 
there is a more comprehensive code for this testing. Medicare requires that the appropriate DEX Z-Code 
identifier be entered adjacent to the CPT code in the comment/narrative field to report comprehensive genomic 
profile (CGP) testing. 
 
We reviewed the rules cited by the Plan and found that they are not applicable to Part B coverage in the State .  
 
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 referred for the genetic panel by a contract provider. The file does not show that the Plan provided 
notice that the genetic panel would not be covered. There were no applicable rules for Medicare Part B in 
Texas to support that this was billed incorrectly. Since there is no Medicare rule which would inform the 
provider of noncoverage for these services as billed, we find that the genetic panel is considered approved by 
the Plan. Therefore, we decided that the Plan has to pay for the cardiovascular genetic panel provided on April 
28, 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 pay for the unspecified preventive procedure provided on May 21, 
2020. 
 
You asked the Plan to pay for the unspecified preventive procedure. You say that you don't understand why the 
procedure was denied after it had been authorized. You say that you can't know if a procedure is covered if it's 
unspecified. The Plan denied your request. The Plan says the claim for the crown was processed according to 
your benefits and the unspecified preventive procedure is not a covered benefit. 
 
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 pay for the 
unspecified preventive procedure provided on May 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a skilled nursing facility stay provided by a 
participating provider on June 10, 2020 to July 16, 2020. 
 
You asked the Plan to waive the copayment for a skilled nursing facility stay. You say that you do not agree 
with these copayments. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
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 $0 
copayment per day for days 1-20. There is a $178 copayment per day for days 21-100 for skilled nursing 
facility (SNF) care/in-network.  
 
You have been asked to pay a $0 copayment per day for days 1-20. There is a $178 copayment per day for days 
21-28 for a skilled nursing facility stay. The total amount you are being asked to pay is $1418 which is less 
than your copayment amount of $1,424 ($178 x 8 days = $1,424). A skilled nursing facility stay falls within the 
skilled nursing facility (SNF) care/in-network 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 stay provided by a participating provider on June 10, 2020 to July 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the nivolumab injection you received on 
May 19, 2020. 
 
You asked the Plan to waive the coinsurance for the nivolumab injection. You say that you don't believe you 
are responsible for this coinsurance The Plan denied your request. The Plan says you were charged this 
coinsurance correctly 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for chemotherapy drugs.  
 
You have been asked to pay 20% coinsurance for the nivolumab injection. The nivolumab injection falls within 
the chemotherapy drugs benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the 
nivolumab injection you received on May 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. 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 LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review has determined that the enrollee does not require services at the LTACH 
that are not available at the acute care hospital where they are currently receiving care. There are no services 
available at the LTACH that the enrollee requires that are not available at the health care setting being offered 
by the health plan. The requested LTACH services are no medically necessary, reasonable, and appropriate for 
the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 
basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient mental health care. 
 
You asked the Plan to pre-approve inpatient mental health care. You say that the stay is medically necessary. 
The Plan denied your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient mental health care. Our 
physician reviewer found based upon review the records provided for the admission of this patient does not 
meet criteria for acute inpatient mental health treatment as this patient was not shown to be a danger to 
themselves or others, no auditory or visual hallucinations. The patient is noted to be cooperative and compliant 
with treatment while not showing any acute threats of safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient mental health care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam CT capture provided on March 26, 2020. 
 
You asked the Plan to pay for the cone beam CT capture. The Plan denied your request. The Plan says the 
service is not a covered benefit. 
 
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 cone 
beam CT capture provided on March 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a telephone assessment provided on April 13, 2020. 
 
You asked the Plan to pay for the telephone assessment. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a telephone assessment provided on April 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the lens upgrades provided on June 10, 2020. 
 
You asked the Plan to reimburse you for the polycarbonate and progressive lens upgrades (V2784, V2781). 
You say that the Plan should reimburse you for the eyeglasses. The Plan denied your request. The Plan says the 
lens upgrades are not a covered benefit. 
 
 
 
 
 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to reimburse you for are considered lens upgrades. Therefore, we decided that 
the Plan does not have to reimburse you for the polycarbonate and progressive lens upgrades provided on June 
10, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a non-radiological test provided by a 
participating provider on June 24, 2020. 
 
You asked the Plan to waive the copayment for a nerve test. You say that this should be waived because of 
Covid-19. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
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 $20 
copayment for outpatient diagnostic tests/non-radiological.  
 
You have been asked to pay a $20 copayment for a nerve test. A nerve test falls within the outpatient diagnostic 
tests/non-radiological 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 non-
radiological test provided by a participating provider on June 24, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a home visit (99350) provided on August 16, 2019. 
 
You asked the Plan to pay for a home visit. You say that this was medically necessary. The Plan denied your 
request. The Plan says this was 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. A home visit cannot be billed by a physician 
unless the physician was actually present in the beneficiary's home. 
 
We find that CPT code 99350 is not supported in the medical record. Specifically, the records do not support 
that the billing physician was present in the enrollee's home. The records indicate that the visit in question was 
a skilled nursing visit performed by a LVN. Based on this information, we decided that Medicare rules for 
coverage of a home visit have not been met. Therefore, we decided that the Plan does not have to pay for a 
home visit (99350) provided on August 16, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a breast ultrasound provided on July 30, 
2020. 
 
You asked the Plan to waive the copayment for a breast ultrasound. You say that you thought that you were just 
getting a mammogram and would not have had the procedure done if you knew you would have such a high 
copayment. 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 $50 
copayment for each x-ray and ultrasound.  
 
You have been asked to pay a $50 copayment for a breast ultrasound. A breast ultrasound falls within the 
outpatient diagnostic tests and therapeutic services and supplies 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 breast ultrasound provided on July 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the TDAP vaccine provided on March 9, 2020. 
 
You asked the Plan to pay for the TDAP vaccine. You say that the vaccine was medically necessary because of 
your medical condition. The Plan denied your request. The Plan says the TDAP vaccine is not covered under 
your Medicare Part B benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the TDAP vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the TDAP vaccine. 
Therefore, we decided that the Plan does not have to pay for the TDAP vaccine provided on March 9, 2020.  
 
Benefits for the TDAP vaccine may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.