Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the 
enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee is not safe to return home. The Plan 
denied your request. The Plan says that the enrollee's needs can be met at a lower level of 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 SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for SNF services. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and mandibular 
partial denture (D5214). 
 
You asked the Plan to pre-approve the complete maxillary denture and mandibular partial denture. You say that 
you have no upper or lower teeth and cannot eat. The Plan denied your request. The Plan says these services 
are not covered under your benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
complete maxillary denture (D5110) and mandibular partial denture (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a recliner chair (E1399) for use with the seat lift 
mechanism. 
 
You asked the Plan to pre-approve a recliner chair. You say that  The Plan denied your request. The Plan says  
 
The Plan must follow Medicare rules. The rules say that seat lift chairs are not covered. Coverage is limited to 
a seat lift mechanism. 
 
Although a seat lift chair may be appropriate, Medicare does not cover this item and the Plan must provide 
coverage only for items that Medicare covers. Therefore, we decided that the Plan does not have to pre-approve 
a recliner chair (E1399) for use with the seat lift mechanism.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 18 additional physical therapy visits. 
 
You asked the Plan to pre-approve the PT visits. The Plan denied your request. The Plan says this is 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 PT visits. Our reviewer says that 
skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that there is no documentation that the unapproved 18 physical 
therapy visits are generally accepted as specific and effective therapy for the patient?s condition. The enrollee 
appears to have plateaued with regard to his function and it is unclear if further therapy will provide any 
additional meaningful benefit. There is no documentation that the unique skills of a professional therapist are 
required to safely and effectively provide treatment, that the services can be safely and effectively performed 
only by a therapist or under the supervision of a therapist for the unapproved 18 physical therapy visits. The 
enrollee appears to have plateaued with regard to his function and it is unclear if further therapy will provide 
any additional meaningful benefit. 
 
 
 
 
 
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 PT visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 18 additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve visual evoked potential testing for the enrollee. 
 
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is not enough scientific evidence to show a benefit from this test. 
 
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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found in most clinical situations, visual evoked potential testing is of limited utility, and the testing has not 
been shown to be useful in the setting described. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve visual evoked potential testing for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300). 
 
You asked the Plan to pre-approve a power seat elevation feature. The Plan denied your request. The Plan says 
that this is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered 
because it is not primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve 
a power seat elevation feature (E2300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you need these to prevent infections. 
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 incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam CT capture and interpretation, problem 
focused detailed and extensive oral evaluation, endodontic therapy, and resin-based composite provided on 
January 28, 2020 and February 5, 2020. 
 
You asked the Plan to pay for the cone beam CT capture and interpretation, problem focused detailed and 
extensive oral evaluation, endodontic therapy, and resin-based composite. You say that you were unaware your 
insurance was through Medicare. You also say that you thought you could go to any dentist that participates 
with your dental plan. The Plan denied your request. The Plan says the treating provider had opted out of 
Medicare prior to this date of service. The Plan also says that they are unable to make payments for services 
provided by a dentist who has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the cone beam CT capture and interpretation, problem focused detailed and extensive oral evaluation, 
endodontic therapy, and resin-based composite provided on January 28, 2020 and February 5, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for family psychotherapy (without the patient present), 50 minutes (CPT 
Code 90846) provided on February 28, 2020. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says that the diagnosis code billed on the claim for date of service February 28, 2020, is not consistent 
with the procedure code billed of 90846. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan failed to support their decision because there was no valid rationale 
given. The diagnosis clearly is supported in the record as are the services described by the code. Therefore, we 
decided that the Plan has to pay for family psychotherapy (without the patient present), 50 minutes (CPT Code 
90846) provided on February 28, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for a hip x-ray (73501) provided on May 12, 2020. 
 
You asked the Plan to pay for the hip x-ray. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says that this service was included in CPT code 73502 
billed by a provider in the same group with the same specialty. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 73501 is supported in the record. Specifically, CPT code 73501 was rendered by a 
different provider than who rendered the column I procedure, CPT code 73502. NCCI edits are not appropriate 
in this case. Based on this information, we decided that Medicare rules for coverage of the hip x-ray have been 
met. Therefore, we decided that the Plan has to pay for a hip x-ray (73501) provided on May 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic radiology services provided on January 2, 2020. 
 
You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for diagnostic radiology services provided on January 2, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe psychiatry virtual visit you had on March 25, 2020.You asked the Plan to waive the copayment forthe psychiatry visit. You say that that you think there should be no charge as this was an initial virtual visit and there were technological issues.  You say that the provider didn't speak clearly or slowly so you had trouble comprehending her.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 $20 copayment for individual therapy with a psychiatrist. You have been asked to pay a $20 copayment for the psychiatry visit. This copayment applies regardless of whether or not the visit was virtual or whether or not you were satisfied with the visit. 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 forthe psychiatry virtual visit you had on March 25, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chiropractic office visit (99214), an x-ray (72020),  
neuromuscular reeducation (97112), electrical stimulation (97032), and a fluid bottle (A9273) provided from 
February 7, 2020 to February 11, 2020. 
 
You asked the Plan to pay for a chiropractic office visit, an x-ray,  neuromuscular reeducation, electrical 
stimulation, and a fluid bottle. You say that these services should be covered. The Plan denied your request. 
The Plan says these services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for a chiropractic office visit (99214), an x-ray (72020),  neuromuscular 
reeducation (97112), electrical stimulation (97032), and a fluid bottle (A9273) provided from February 7, 2020 
to February 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions (D7140) and the panoramic x-ray (D0330) 
provided on May 18, 2020. 
 
You asked the Plan to pay for the dental services. You say that you did not know that the extractions that you 
received would not be covered until you received the bill. You also say that you can only afford to pay $50 on 
the bill that you received. The Plan denied your request. The Plan says contract list the specific dental services 
that are covered. The Plan says that extractions are not listed as a covered service. The Plan also says 
panoramic x-rays are not listed as covered service either. 
 
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 dental services you received are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
extractions (D7140) and the panoramic x-ray (D0330) provided on May 18, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation service 
(A0427) provided on February 2, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment was applied correctly to the 
service provided. 
 
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 $270 
copayment for in-network or out of network emergency and non-emergency ground ambulance services, 
regardless of the number of trips.  
 
You have been asked to pay a $270 copayment for the out of network, emergent ground ambulance service 
provided. 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 ambulance transportation service (A0427) 
provided on February 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the external electrocardiographic recording (93227) provided 
on January 6, 2020. 
 
You asked the Plan to pay for the electrocardiographic recording. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says the claim did not include the 
appropriate primary, first-listed or principal diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the electrocardiographic recording have not been met. Specifically, diagnosis code R65.10 includes 
a "code first" note. This means that this diagnosis code and the underlying condition should be listed first. 
Therefore, we decided that the Plan does not have to pay for the external electrocardiographic recording 
(93227) provided on January 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe acute inpatient hospital care provided on April 24, 2019.You asked the Plan to pay forthe acute inpatient hospital care. The Plan denied your request. The Plan says inpatient admission was not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 the acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights.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 acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay forthe acute inpatient hospital care provided on April 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the coronectomy (D7251) provided on May 28, 2020. 
 
You asked the Plan to pay for the dental service. You say that you were advised by a Plan representative that 
the extraction of a wisdom tooth would be covered. You say that the dental service should be covered since you 
were advised it would be. The Plan denied your request. The Plan says while extractions are a covered service, 
a coronectomy is different from an extraction. The Plan also says the coronectomy 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 coronectomy that you received is 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
coronectomy (D7251) provided on May 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified preventive dental service (D1999) provided 
on June 2, 2020. 
 
You asked the Plan to pay for the unspecified preventive dental service. You say that your previous exam was 
only for an x-ray. You say that the services you received should be covered. The Plan denied your request. The 
Plan says the unspecified preventive dental service is 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the unspecified preventive dental 
service is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay 
for the unspecified preventive dental service (D1999) provided on June 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 73562) provided. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
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 73562 is "Radiologic examination, knee; 3 views". 
 
We asked our coding 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 the services. Our reviewer says that the use 
of CPT code 73562 is not supported by the records provided. Our coding reviewer found that the radiology 
report documents report released however, does not support that this service was 
performed. 
 
We looked at this coder?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 pay for the services (CPT 73562).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services. 
 
You asked the Plan to pay for home health services. You say that you were told authorization was not required. 
The Plan denied your request. The Plan says a physician must certify the need for home health services. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. The rules also say that the provider, supplier, or beneficiary, as appropriate, must 
furnish to the intermediary or carrier sufficient information to determine whether payment is due and the 
amount of payment. 
We looked at the file and Medicare rules. No medical records, including a certification of the need for home 
health services by a physician, have been submitted. Based on this information, we decided that Medicare rules 
for coverage of home health services have not been met. Therefore, we decided that the Plan does not have to 
pay for home health services.