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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that that this is necessary for you to return to being 
independent as quickly as possible. The Plan denied your request. The Plan says you can be treated at a lower 
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 complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
infection of lumbar surgical site after recent lumbar decompression surgery. You have been discharged to a 
skilled nursing facility where you are receiving intravenous antibiotics and therapy services. You medical 
problems are stable. There are no identified problems that need inpatient medical management. There are no 
complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record 
supports a need for physical and occupational therapy, but it does not support a need for an intensive 
rehabilitation therapy program. There is not a reasonable expectation that you 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair glide. 
 
You asked the Plan to pre-approve a stair glide. You say that you have to sleep on the couch in pain all the 
time. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on July 
23, 2020. 
 
You asked the Plan to pay for the dental service. You say that you have been billed for this service in the past 
exhausting your benefit. You also say that none of the providers actually performed the service. The Plan 
denied your request. The Plan says 2 comprehensive oral evaluations are covered per calendar year. The Plan 
says that the frequency limit has been exceeded. 
 
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 2 per calendar 
year has been exceeded. The record shows that the plan paid for comprehensive oral evaluations that you 
received on June 9, 2020 and June 30, 2020. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation (D0150) provided on July 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain crown (D2740) for tooth # 10. 
 
You asked the Plan to pre-approve the dental service. You say that tooth # 10 is damaged and on the brink of 
fracturing due to a root canal. You say that you need a porcelain crown because a metal infused porcelain 
crown would not be suitable for an anterior tooth. You also say that your dentist only does porcelain crowns. 
The Plan denied your request. The Plan says porcelain crowns are not listed as a covered service. 
 
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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a porcelain 
crown (D2740) for tooth # 10.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient mental health care provided to the enrollee from 
April 29, 2020 to May 11, 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 exhausted his inpatient medical benefit. The rules say a plan must disclose 
to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and 
coinsurance). The enrollees contract with the Plan clearly says that enrollees must pay 90 maximum days for 
in a benefit period. The Plan provided documentation that shows between 2019 and continuing into 2020, the 
enrollee has exhausted the inpatient benefit. Therefore, we decided that the Plan does not have to pay for 
inpatient mental health care provided to the enrollee from April 29, 2020 to May 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an injection provided to the enrollee on February 4, 2020 and billed under code 64495.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 Medicare billing criteria were not met.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for this service. Our reviewer says that Medicare billing criteria are not met. Our physician reviewer found the medical records provided were not legible and we are unable to confirm the services performed. 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 Plandoes not have to pay for an injection provided to the enrollee on February 4, 2020 and billed under code 64495.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has a lack of motion, and needs intense 
care. The Plan denied your request. The Plan says the enrollee does not have complex rehab needs, and does 
not need to see a rehab physician 3 times a week. 
 
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 physician reviewer found 
that the enrollee was admitted to the acute hospital for treatment of a hip fracture after a fall. Her medical 
problems are stable. The complexity of her nursing, medical and rehabilitation needs does not require an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There is not a reasonable 
expectation that she will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF. The medical record supports a need for physical and occupational therapy, but it 
does not support a need for an intensive rehabilitation therapy program. 
 
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 pre-approve physician's services to be provided by the out-of-
network physician. 
 
You asked the Plan to pre-approve the physician's services. You say that you had a bad experience with the in-
network provider. The Plan denied your request. The Plan says the service is available within the network and 
your condition is not an emergency. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the out-of-network physician.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided on June 
9, 2020, to June 10, 2020. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you disagree with the 
copayment as charged because you are not satisfied with the care you received in the emergency room. The 
Plan denied your request. The Plan says the copayment applied correctly in this case. 
 
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 $100 
copayment for emergency care.  
 
You have been asked to pay a $200 total copayment for two emergency room visits on June 9th and June 10th. 
These services provided fall within the emergency care 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 the emergency room visit provided on June 9, 2020, to June 10, 2020.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on May 18, 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 medical services provided on May 18, 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 outpatient office visit for the evaluation and management of 
an established patient (99214) Arthrocentesis, aspiration and/or injection (20611) provided January 15, 2020. 
 
You asked the Plan to pay for the office visit and injection services. You say that the records provided should 
support the necessity of the service in dispute. The Plan denied your request. The Plan says the records do not 
support the billed service. There is insufficient documentation to corroborate the services and confirm that 
Medicare coverage has been met. 
 
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 99214 and 20611 is not supported in the medical record. Specifically, for 
CPT code 99214 25 57 (1 unit), 99214 is included in CPT code 20611. A -57 modifier may not be used on an 
evaluation and management visit billed on the day of or the day before a procedure with a 0 or 10-day global 
period. For CPT code 20611 59 (1 unit), the documentation submitted did not include documentation of 
permanently recorded images to support the billed charge. Based on this information, we decided that Medicare 
rules for coverage of the office visit and injection services have not been met. Therefore, we decided that the 
Plan does not have to pay for outpatient office visit for the evaluation and management of an established 
patient (99214) Arthrocentesis, aspiration and/or injection (20611) provided January 15, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for lodging costs for dates of service September 26, 
2019, September 27, 2019 and October 8, 2019. 
 
You asked the Plan to reimburse you for the lodging. You say that your lodging is covered during visits like 
this. The Plan denied your request. The Plan says the services are not related to evaluation for liver transplant 
services. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The record shows the expenses were not related to evaluation of a 
transplant or the transplant. Based on this information, we decided that Medicare rules for coverage of the 
lodging have not been met. Therefore, we decided that the Plan does not have to reimburse you for lodging 
costs for dates of service September 26, 2019, September 27, 2019 and October 8, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for GeneSight assay testing provided. 
 
You asked the Plan to pay for lab test. You say that no basis exists for the Plan to deny coverage of this service 
that is covered by Medicare. The Plan denied your request. The Plan says the denial of payment for this testing 
is correct, because this testing does not meet the Medicare criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that GeneSight testing must be ordered by a licensed 
psychiatrist or neuropsychiatrist, and claims submitted by non-physician providers will be denied. Medicare 
rules also say that a physician order or clear intent to order specific lab services is required for covered lab 
services. 
 
We looked at the file and Medicare rules. The ordering provider for this testing is not a licensed psychiatrist or 
neuropsychiatrist but is a non-physician provider. Furthermore, the order form submitted is not signed or dated 
by the ordering practitioner and therefore cannot be considered a valid lab order for this specific lab service. 
Based on this information, we decided that Medicare rules for coverage of lab test have not been met. 
Therefore, we decided that the Plan does not have to pay for GeneSight assay testing provided.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says you do not require 
close medical supervision, or have complex rehab needs. 
 
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 physician reviewer found 
that you were admitted to the acute hospital for pneumonia and COPD exacerbation. Your medical problems 
are stable. The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The medical record supports a need for 
physical and occupational therapy, but it does not support a need for an intensive rehabilitation therapy 
program. 
 
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 pre-approvecore build up (D2950) for tooth # 18.You asked the Plan to pre-approvethe dental service. You say that the services are necessary.The Plan denied your request. The Plan says core build up is not a covered service.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 core build up is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvecore build up (D2950) for tooth # 18.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel rendered on June 26, 2019. 
 
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 Guardant360 testing is covered for patients with 
NSCLC. 
 
We looked at the file and Medicare rules. The file shows that the testing was not performed for a diagnosis of 
NSCLC. 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 Guardant360 panel rendered on June 
26, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient mental health services you 
received from June 27, 2020, to July 10, 2020. 
 
You asked the Plan to waive the copayment for the inpatient mental health services. You say that you should 
not be held responsible for this copayment since this was an involuntary admission. The Plan denied your 
request. The Plan says you were charged this copayment 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 a $210 
copayment per day for days 1-7, and a $0 copayment for days 8-90 for inpatient mental health care.  
 
You have been asked to pay a $210 copayment per day for days 1-7 for the inpatient mental health services. 
This copayment applies regardless of the reason for the admission. 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 inpatient mental health services you received from June 27, 2020, to July 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 3 extractions (D7210) provided on August 17, 2020. 
 
You asked the Plan to pay for the dental services. You say that the dentist should get paid. You say that the 
dentist did a good job. You also say that you had to do this same thing last time. The Plan denied your request. 
The Plan says 5 extractions every year are covered. The Plan also says that the frequency limit has been 
exceeded. 
 
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 and extractions are a covered service, 
the frequency limit of 5 every calendar year has been exceeded. The record shows that the plan paid for 2 
extractions that you received on May 13, 2020 and 3 additional extractions that you received on June 24, 2020. 
Therefore, we decided that the Plan does not have to pay for the 3 extractions (D7210) provided on August 17, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chemotherapy services provided, by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the chemotherapy services. You say that the wrong insurance information was 
provided for this date of service. The Plan denied your request. The Plan says prior authorization was not 
obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
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 chemotherapy services provided, by an 
out of network (OON) provider.