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

We decided that the Plan does not have to pay for the limited oral evaluation, panoramic x-ray, the 8 
extractions, the 4 fillings, and the palliative emergency care provided from June 15, 2020, to September 17, 
2020. 
 
You asked the Plan to pay for the dental services. You say that when you purchased this policy, you were not 
advised that there was a list of providers that you needed to adhere to. You say that you were not informed of 
this until July 31, 2020. The Plan denied your request. The Plan says the dental provider in this case is out of 
network. The Plan says that care rendered by a provider that is not part of our supplemental dental network is 
not covered. 
 
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, services that you receive out of 
network are not covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
limited oral evaluation, panoramic x-ray, the 8 extractions, the 4 fillings, and the palliative emergency care 
provided from June 15, 2020, to September 17, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have pay for an emergency department visit provided on February 18, 2020. 
 
You asked the Plan pay for the emergency department visit. You say that the claim was inappropriately down 
coded. You say that the documentation provided supports that the guidelines for coverage have been met. The 
Plan denied your request. The Plan says they did not receive a primary carrier's Explanation of Benefits. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for the emergency department visit until the primary insurer has denied the claim for these services. Therefore, 
we decided that the Plan does not have pay for an emergency department visit provided on February 18, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for positron emission tomography (PET) services billed with 
code 78815 for date of service September 10, 2019. 
 
You asked the Plan to pay for the PET scan billed with code 78815. You say that the service in dispute is not 
inclusive and should pay separately. The Plan denied your request. The Plan says the code in dispute is billed 
 
The Plan must follow Medicare rules. Medicare rules say that when a NCCI edit exists between two codes, 
generally only the Column 1 code is payable, unless the modifier indicator for the code is 1 and a clinically 
appropriate modifier is used to bypass the edit.  
 
CPT code 78815 is a Column 2 code in relation to code 78816. CPT code 78815 has a modifier indicator of 0, 
meaning that it cannot be paid when billed with CPT code 78816. We looked at the file and Medicare rules. 
Based on this information, we decided that Medicare rules for coverage of the PET scan billed with code 78815 
have not been met. Therefore, we decided that the Plan does not have to pay for positron emission tomography 
(PET) services billed with code 78815 for date of service September 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 3D rendering with interpretation and reporting of 
computed tomography services coded 76376 provided on July 19, 2020. 
 
You asked the Plan to pay for the 3D rendering with interpretation and reporting of computed tomography 
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 76376 is 3D rendering with interpretation and reporting 
of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image 
postprocessing under concurrent supervision; not requiring image postprocessing on an independent 
workstation. 
 
We find that CPT code 76376 is not supported in the medical record. Specifically, this code is to be used in 
conjunction with code(s) for base imaging procedures. Review of the claim shows that this was the only code 
billed on the claim. Based on this information, we decided that Medicare rules for coverage of the 3D rendering 
with interpretation and reporting of computed tomography services have not been met. Therefore, we decided 
that the Plan does not have to pay for the 3D rendering with interpretation and reporting of computed 
tomography services coded 76376 provided on July 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for rehabilitation services provided on Jul 6, 2020, to July 21, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for rehabilitation 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 rehabilitation services provided on Jul 6, 2020, to 
July 21, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device/motorized scooter. 
 
You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 scooter. Our reviewer says that the 
requested scooter is not medically reasonable or necessary. Our physician reviewer found the documentation 
does not support that your mobility deficit impairs participation in MRADLs in the home. The mobility deficit 
can be helped by a walker. The documentation does not support that you can safely operate this device in the 
home. 
 
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 scooter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power mobility device/motorized scooter.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health aide or certified nurse assistant services 
coded S9122 provided on June 12, 2020. 
 
You asked the Plan to pay for the home health aide or certified nurse assistant 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 S9122 is home health aide or certified nurse assistant, 
providing care in the home; per hour. 
 
We find that CPT code S9122 is not supported in the medical record. Specifically, this code has a status code 
of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code 
for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for 
coverage of the home health aide or certified nurse assistant services have not been met. Therefore, we decided 
that the Plan does not have to pay for the home health aide or certified nurse assistant services coded S9122 
provided on June 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services rendered on August 
28, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that you are forced to use the hospital 
for blood work because there are not freestanding facilities. The Plan denied your request. The Plan says the 
copayment was applied 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 $40 
copayment for in-network lab services at an outpatient hospital.  
 
Review of the file shows that you received laboratory services on August 28, 2020. You have been asked to 
pay a $40 copayment for these services. These services fall within the in-network lab services at an outpatient 
hospital 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 laboratory services 
rendered on August 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care services provided on 
February 27, 2020, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the subsequent 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 rendered 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 subsequent nursing facility care services 
provided on February 27, 2020, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services received on September 29, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there was no authorization for the 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 rendering laboratory 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 lab services received on September 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) 
(72141) provided on August 6, 2020. 
 
You asked the Plan to waive the copayment for a MRI. You say that the provider gave you incorrect 
copayment information. The Plan denied your request. The Plan says this processed 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 $100 
copayment for each Medicare-covered MRI.  
 
You have been asked to pay a $25 copayment for a MRI. The Plan has elected to honor the information given 
to you by the provider and has lowered your copayment. 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 magnetic resonance imaging (MRI) (72141) provided on August 6, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intraoperative electroencephalography (EEG) provided 
on May 26, 2020. 
 
You asked the Plan to pre-approve intraoperative EEG. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because 
the clinical value of intraoperative EEG in this setting has not been demonstrated. 
 
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 intraoperative EEG. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is a lack of records submitted to justify why this procedure was necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intraoperative EEG have not been met. Therefore, we decided that the Plan does 
not have to pre-approve intraoperative electroencephalography (EEG) provided on May 26, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 23, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the outpatient mental health services. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says prior 
authorization was not obtained. 
 
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 June 23, 2020 by 
an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve the SNF admission. You say that the enrollee needs this care to assist him with functional issues. The Plan denied your request. The Plan says the enrollee does not need daily skilled care.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is a 90-year-old male with dementia and hypothyroidism. From a nursing perspective, the beneficiary received oral medications. The beneficiary had stable vital signs. He was alert and forgetful. Regarding rehabilitation services, the beneficiary received PT, ST and OT. The beneficiary was at a stand-by assist to contact guard assist level with functional mobility including gait to 50 feet. The beneficiary required varying assist with daily living activities. He had cognitive impairment.

There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs; however, these do not require daily skilled therapy. This beneficiary does not meet severity of illness or intensity of service criteria for 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 the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the IRF admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of 
care. 
 
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 enrollee does not require LTACH services that are not already available at the 
current facility. Our reviewer found that there are no services at the LTACH that the enrollee requires that are 
not already available and covered at the current facility. Our physician reviewer also found that this request for 
LTACH services will be considered not medically necessary at this time. Transfer to a lower level of care may 
be considered when treatment has completed. 
 
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 LTACH services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 16 additional PT visits. 
 
You asked the Plan to pre-approve the additional PT visits. You say that the physical therapy services are 
medically necessary for the enrollee. The Plan denied your request. The Plan says 16 additional PT visits 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 the additional PT visits. 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 documentation indicates the enrollee has had prior 
extensive therapy. Therapy has been working on improving gait speed, endurance, strengthening. Our reviewer 
found that the records do not demonstrate that the enrollee's functional level requires the ongoing unique skills 
of a professional therapist to provide treatment safely and effectively, or that the services can be safely and 
effectively performed only by a therapist, or under the supervision of a therapist. The enrollee and caregiver 
can continue an independent home exercise program. Our physician reviewer also found that the requested 
services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a 
qualified therapist are not required to establish, design and/or deliver a program to maintain the enrollee's 
current condition or to 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 the additional PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 16 additional PT visits.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 71045) provided on February 25, 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 records show that the services in question were billed on a 
duplicate claim to one previously processed and paid by the Plan. Duplicate claims are not payable. 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 services (CPT 71045) provided on February 25, 2020.