Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the advance care planning including the explanation and 
discussion of advance directives such as standard forms services coded 99497 provided on March 13, 2020. 
 
You asked the Plan to pay for the advance care planning services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the 
documentation. 
 
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 99497 is advance care planning including the explanation 
and discussion of advance directives such as standard forms (with completion of such forms, when performed), 
by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, 
family member(s), and/or surrogate. 
 
We find that CPT code 99497 is not supported in the medical record. Specifically, the documentation submitted 
did not include documentation of an advance care planning including the explanation and discussion of 
advance directives such as standard forms (with completion of such forms, when performed), by the physician 
or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), 
and/or surrogate. Based on this information, we decided that Medicare rules for coverage of the advance care 
planning services have not been met. Therefore, we decided that the Plan does not have to pay for the advance 
care planning including the explanation and discussion of advance directives such as standard forms services 
coded 99497 provided on March 13, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement of nails (11721) established patient 
domiciliary/rest home visit (99334) provided on February 25, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the domiciliary/rest home visit. You say that it is the facilities responsibility to 
obtain proper pre-certification and pre-authorization. Your doctors have no control over this protocol and rely 
on the facility to obtain proper permissions. The Plan denied your request. The Plan says enrollee's must 
receive their medical services from an in-network provider with the exception being urgent or emergent 
services. The plan says that non-emergent services with non-contracted providers require prior authorization 
before services being rendered. 
 
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 debridement of nails (11721) established 
patient domiciliary/rest home visit (99334) provided on February 25, 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 the initial hospital care rendered on March 5, 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 the services are not covered. 
 
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 99222 is initial hospital inpatient care, typically 50 
minutes per day. 
 
We find that CPT code 99222 is not supported in the medical record. Specifically, the documentation supports 
the billing of one unit of this code, which has been approved and paid. There is no documentation to support 
billing of further units of initial hospital care. 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 
initial hospital care rendered on March 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) rendered by the out of network 
(OON) provider on March 23, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the office visit (99214) rendered by the out of network (OON) provider on March 23, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight physical therapy (PT) visits. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the submitted records show that you had a spinal fracture and have 
been receiving PT. There is no documentation to support that the eight further PT visits are generally accepted 
as specific and effective therapy for your condition. The records do not support that you require the unique 
skills of a professional therapist to safely and effectively provide treatment. The services are not part of a 
maintenance program and are not reasonable or medically necessary to maintain your current condition or 
prevent or slow further 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve eight physical therapy (PT) visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar/sacral facet joint radiofrequency neurolysis for
the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no spine pain.
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 the services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found temporary or prolonged abolition of the pain suggests that the facet joint(s) are the source of the
symptoms and appropriate for treatment. The provided medical records do not document that the enrollee has
satisfied these requirements. Therefore, this procedure is not medically necessary and reasonable.
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 a lumbar/sacral facet joint radiofrequency neurolysis for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network oncologist/hematologist. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are network providers available that are open and accepting new patients. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral to an out-of-network oncologist/hematologist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial denture (D5212). 
 
You asked the Plan to pre-approve the partial denture. You say that the service is medically necessary. The 
Plan denied your request. The Plan says mastication is not sufficiently impaired to justify the denture. 
 
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 the partial 
denture when the services are medically necessary and reasonable.  
 
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 partial denture. Our reviewer says 
that the requested partial denture is not medically necessary. Our physician reviewer found the records and 
radiographs provided show that in the mandible one tooth is missing (#18). Replacing #18 with a partial 
denture would not increase the masticatory function to any appreciable degree. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the partial denture have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a partial denture (D5212).
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 the enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services or 
to require 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on February 26, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The 
Plan says that the member's primary care physician did not refer these services. 
 
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 physician services provided on February 26, 2020 
by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray and scaling in presence of generalized 
moderate or severe gingival inflammation provided on March 18, 2020. 
 
You asked the Plan to pay for the panoramic x-ray and scaling. You say that you were assured that this 
provider was in the Plan's network. You also say that you did not request these services, and just wanted your 
teeth cleaned. The Plan denied your request. The Plan says these services are not a benefit under the 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 
panoramic x-ray and scaling in presence of generalized moderate or severe gingival inflammation provided on 
March 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial nursing facility care services provided on March 9, 
2020. 
 
You asked the Plan to pay for the initial nursing facility care services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services are not payable as 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 [Enter billing code at issue (e.g. 43856, K0002, etc.)] is 
initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key 
components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical 
decision making that is straightforward or of low complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of 
low severity. Typically, 25 minutes are spent at the bedside and on the patient's facility floor or unit. 
 
We find that CPT code [Enter billing code at issue (e.g. 43856, K0002, etc.)] is not supported in the medical 
record. Specifically, The NPI website shows NPI 1942316641 has multiple taxonomies of ?363L00000X - 
Nurse Practitioner? and ?163WW0000X - Registered Nurse Wound Care? but the rendering taxonomy 
submitted on the claim was 163WW0000X - Registered Nurse Wound Care which corresponds to registered 
nurse.     It appears the incorrect rendering taxonomy was submitted on the claim, which resulted in this edit 
invoking. A provider should submit the appropriate/correct taxonomy on their submitted claim. Based on this 
information, we decided that Medicare rules for coverage of the initial nursing facility care services have not 
been met. Therefore, we decided that the Plan does not have to pay for the initial nursing facility care services 
provided on March 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite filling rendered on May 8, 2020. 
 
You asked the Plan to pay for these services. You say that you were in pain and needed urgent dental care. The 
Plan denied your request. The Plan says the services are 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 resin-
based composite filling rendered on May 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bronchoscopy billed for services provided on November 
5, 2019. 
 
You asked the Plan to pay for the billed services. You say that the enrollee has had issues since she was first 
seen in your office. The Plan denied your request. The Plan says the billed service cannot be verified. 
 
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 31635 is bronchoscopy, rigid or flexible, including 
fluoroscopic guidance, when performed; with removal of foreign body. We find that CPT code 31635 is not 
supported in the medical record. Based on the information provided, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for the bronchoscopy 
billed for services provided on November 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 13, 2020 to 
March 26, 2020. 
 
You asked the Plan to pay for the home health services. You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says payment is not allowed for this service because it was billed with an 
incorrect type of bill code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with a 4-digit type of bill code. 
 
We find that the home health services cannot be paid as billed due to a recorded error involving code 321. 
Based on this information, we decided that Medicare rules for coverage of the home health services have not 
been met. Therefore, we decided that the Plan does not have to pay for the home health services provided from 
March 13, 2020 to March 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99213) Federally qualified health 
center (FQHC) visit, established patient (G0497) provided on March 4, 2020 by an out of network (OON) 
provider. 
 
You asked the Plan to pay for the outpatient FQHC office visit. You say that you respectfully request 
reconsideration of the prior decision and issue payment for services rendered. The Plan denied your request. 
The Plan says enrollee's must receive their medical services from an in-network provider with the exception 
being urgent or emergent services. Non-emergent services with non-contracted providers require prior 
authorization before services being rendered. 
 
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 outpatient office visit (99213) Federally 
qualified health center (FQHC) visit, established patient (G0497) provided on March 4, 2020 by an out of 
network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for outpatient surgery provided on January 30, 
2020. 
 
You asked the Plan to waive the coinsurance for outpatient surgery. You say that you were not aware that if 
you had stayed in the hospital your charges would be less. The Plan denied your request. The Plan says the 
coinsurance 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 a 20% 
coinsurance for surgery performed at an in-network outpatient facility.  
 
The allowed amount of the claim is $14,954.24, resulting in a coinsurance obligation of $2,990.85 for 
outpatient surgery. Outpatient surgery falls within the outpatient hospital services 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 outpatient surgery provided on January 30, 2020.