Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation, panoramic x-ray, and 
complete upper and lower denture provided on May 26, 2020. 
 
You asked the Plan to pay for the comprehensive oral evaluation, panoramic x-ray, and complete upper and 
lower denture. You say that it was never brought to your attention that you had to go to a certain dental office. 
You say that you were informed the office took your insurance, so you thought everything was in your favor. 
The Plan denied your request. The Plan says out-of-network dental services are not covered benefits. 
 
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, out-of-network dental services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation, panoramic x-ray, and complete upper and lower denture provided on May 26, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have waive the copayment for an outpatient surgery and coinsurance for an 
injection provided by a participating provider on April 30, 2020. 
 
You asked the Plan to waive the copayment for an outpatient surgery and coinsurance for an injection. You say 
that you've never had to pay more than your copayment before. The Plan denied your request. The Plan says 
the correct copayment and coinsurance have 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 $25 
copayment for outpatient surgery/in-network and a 20% coinsurance for Medicare Part B prescription drugs/in-
network.  
 
You have been asked to pay a $25 copayment for an outpatient surgery and a 20% coinsurance of the allowed 
amount for an injection. The total allowed amount is $893.40. The amount you are being asked to pay for an 
injection is $178.68 ($893.40 x 20% = $178.68). The total amount you are being asked to pay is $203.68 
($178.68 x 20% = $203.68).  
 
An outpatient surgery falls within the outpatient surgery/in-network benefit category and an injection falls 
within the Medicare Part B prescription drugs/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 an outpatient surgery and 
coinsurance for an injection provided by a participating provider on April 30, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from April 
1, 2019 to April 29, 2019. 
 
You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
 
 
 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the Request 
for Anticipated Payment (RAP) claim was not billed. In addition, the billed claim was missing the required Q-
codes. Therefore, we decided that the Plan does not have to pay for the home health services provided to the 
enrollee from April 1, 2019 to April 29, 2019.
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. The Plan denied your request. The Plan says LTACH 
admission is not medically necessary. 
 
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 that ongoing care needs include respiratory support with tracheostomy care, 
suctioning, surveillance laboratory studies, tube feeding until clearance for oral intake, and therapy services. 
The documentation does not support that the enrollee in this case requires services at the LTACH that are not 
available at the acute care hospital where he is currently receiving care. There are no required medical services 
identified that are available at the LTACH, that are not available at the current health care setting being offered 
by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee at this time. 
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
March 1, 2019 to March 29, 2019. 
 
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says a RAP claim was not billed an the billed claim 
was not a, "No-RAP." 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
 
 
Medicare rules for completing the claim for home health services have not been met. Specifically, there is no 
evidence that a RAP was submitted. Therefore, we decided that the Plan does not have to pay for the home 
health services provided to the enrollee from March 1, 2019 to March 29, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care visit of 30-74 minutes (99291)  and critical care, 
each additional 30 minutes (99292). 
 
You asked the Plan to pay for the critical care visit. You say that the medical records provided will show proof 
of medical necessity. The Plan denied your request. The Plan says the records do 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, we find that CPT code is not 
supported in the medical record. Specifically, the documentation does not include the time spent providing this 
service and the documentation did not support a critical care visit of 30-74 minutes was performed on the billed 
date of service. We have also confirmed that code 99292 has a bundled relationship with code 99291 and 
 
 
cannot be paid as billed. The required primary service CPT code is denied. Therefore, 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 critical care visit of 30-74 minutes (99291) and critical care, 
each additional 30 minutes (99292).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MYOBLOC. 
 
You asked the Plan to pre-approve MYOBLOC. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Botulinum Toxin is covered for the indications 
established in the above LCD. 
 
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 MYOBLOC. Our reviewer says that 
MYOBLOC is not medically reasonable and necessary for the enrollee in this case. Our physician reviewer 
found that the enrollee's diagnoses do not reflect a "spastic condition" as defined by the LCD or the associated 
LCA (Billing and Coding: Botulinum Toxin Type A & B (A57474)). MYOBLOC is also not otherwise FDA 
approved for use in the enrollee's diagnosis, nor is it supported for use within the Medicare accepted 
Compendia for the enrollee's diagnoses of muscle spasm and piriformis syndrome. In this setting, the use of 
MYOBLOC would be noncovered by Medicare as the LCD states: "All other uses in the treatment of other 
types of spasm will be considered as investigational". 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MYOBLOC have not been met. Therefore, we decided that the Plan does not 
have to pre-approve MYOBLOC.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood smear services coded 85060 provided on May 14, 
2020. 
 
You asked the Plan to pay for the blood smear 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 payable. 
 
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 85060 is blood smear, peripheral, interpretation by 
physician with written report. 
 
We find that CPT code 85060 is not supported in the medical record. Specifically, No TC billing is recognized 
because payment for the underlying clinical laboratory test is made to the hospital, generally through the PPS 
rate. No payment is recognized for code 85060 furnished to hospital outpatients or non-hospital enrollees. The 
physician interpretation is paid through the clinical laboratory fee schedule payment for the clinical laboratory 
test. Based on this information, we decided that Medicare rules for coverage of the blood smear services have 
not been met. Therefore, we decided that the Plan does not have to pay for the blood smear services coded 
85060 provided on May 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a back brace (L0650) provided on February 4, 2020. 
 
You asked the Plan to pay for a back brace. You say that this was medically necessary. The Plan denied your 
request. The Plan says this was not supplied in connection with a covered telehealth visit. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a back brace (L0650) 
provided on February 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair expandable controller upgrade 
(E2377), access harness upgrade (E2313), and an electronic connection between the wheelchair controller and 
two or more power seating system motors (E2311). 
 
You asked the Plan to pre-approve the power wheelchair expandable controller upgrade, the access harness 
upgrade, and the electronic connection item. You say that the records provided support the need for the 
requested items. The Plan denied your request. The Plan says Medicare guidance states that upgraded 
electronics cannot be covered as there is not a medical need to control the requested power options through the 
joystick. 
 
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 power wheelchair expandable 
controller upgrade, the access harness upgrade, and the electronic connection item. Our reviewer says that the 
requested items are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation does not reveal that the enrollee requires other types of proportional input devices or 
non-proportional input devices. The enrollee does not need to operate 3 or more powered seating actuators 
through the drive control, a separate display, other electronic devices, or an attendant control. The enrollee's 
functional ability should be sufficient to control any power options through their individual switches. 
 
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 power wheelchair expandable controller upgrade, the access harness 
 
 
upgrade, and the electronic connection item have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power wheelchair expandable controller upgrade (E2377), access harness upgrade 
(E2313), and an electronic connection between the wheelchair controller and two or more power seating 
system motors (E2311).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core build up (D2950 x 3), the crowns (D2752 3), and the 
gum surgery (D4211) provided from June 10, 2019, to July 3, 2019. 
 
You asked the Plan to pay for the dental services. You say that you only wanted dental work done that would 
be covered. You say that you cannot afford to pay for any elective work that was not pre-approved by your 
insurance company. You say that you were advised the services would be covered. The Plan denied your 
request. The Plan says the core build up is not listed as covered. The Plan says gum surgery is not listed as a 
covered service. The Plan also says that 2 crowns are covered per year after a 6 month waiting period. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and crowns are listed as a covered 
service, the 6 month waiting period had not passed prior to receiving the crowns. The record shows that you 
became active with the Plan 4 months prior to receiving these services. Core build up and gum surgery are not 
listed as covered services. Additionally, the record shows a financial agreement which you signed stating you 
would pay the balance of the bill after the Plan agreed to write-off half. Therefore, we decided that the Plan 
does not have to pay for the core build up (D2950 x 3), the crowns (D2752 3), and the gum surgery (D4211) 
provided from June 10, 2019, to July 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on February 19, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes cannot 
be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition stating exactly which testing was to be performed. 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 pay for the drug testing services provided on February 19, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
November 1, 2019, to November 30, 2019. 
 
You asked the Plan to pay for home health 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 payable. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the Request 
for Anticipated Payment (RAP) claim was not submitted. Therefore, we decided that the Plan does not have to 
pay for the home health services provided to the enrollee from November 1, 2019, to November 30, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve SNF admission. The Plan denied your request. The Plan says SNF 
admission is not medically necessary. 
 
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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee does not require skilled 
nursing services with the specialized skill, knowledge, and judgment of a skilled professional nurse required to 
safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not 
have complex wound care or other ongoing SNF level skilled nursing needs. The enrollee's functional level 
does not require skilled therapy services with the specialized skill, knowledge, and judgment of a qualified 
therapist to safely and effectively provide medically necessary and reasonable treatment only in a SNF. The 
enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a 
"daily basis" in a SNF. As a practical matter, this enrollee does not require the necessary services on an 
inpatient basis, in a skilled nursing facility setting. 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) admission.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detection services provided on May 13, 
2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the infectious agent detection services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered 
benefit. 
 
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 infectious agent detection services provided on 
May 13, 2020, by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services (CPT 80074) provided to the enrollee from 
February 18, 2020, to February 20, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a duplicate 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied.  
 
We looked at the file and Medicare rules. The documentation shows that the services in question were billed on 
a duplicate claim to one previously processed and paid by the Plan. 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 pay for the lab services (CPT 80074) provided to the enrollee from February 18, 2020, to February 20, 
2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
September 2, 2019 to September 30, 2019. 
 
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says a RAP claim was not billed and the billed 
claim was not a "No-RAP."` 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, there is no 
evidence that a RAP has been submitted. Therefore, we decided that the Plan does not have to pay for the home 
health services provided to the enrollee from September 2, 2019 to September 30, 2019.