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

 
We decided that the Plan does not have to pay for the medical services provided on June 17, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for [Shorter description of ITEM or SERVICE at issue, e.g. "a power wheelchair"]. 
You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have 
prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. 
The Plan has network providers available who can provide the 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 17, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for screening lab services provided on June 18, 2020. 
 
You asked the Plan to pay for these lab services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the services provided were denied because codes 83036, 84443, and 84439 are not a 
Medicare benefit for the diagnoses listed on the claim when ordered for screening purposes. There is no 
documentation of a valid diagnosis for which this testing may be done on the claim form. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. The test at issue in this appeal was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for screening lab services provided to the enrollee on June 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services (D0150, D1110, D0210) provided 
August 20, 2020. 
 
You asked the Plan to pre-approve the dental services. You say that the dental services should be covered. The 
Plan denied your request. The Plan says dental services provided out-of-network are 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, the requested items or services are not 
among those covered under this benefit. Only dental services obtained through a plan-contracted provider are 
eligible for coverage. Therefore, we decided that the Plan does not have to pre-approve dental services (D0150, 
D1110, D0210) provided August 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve generator, neurostimulator (implantable), with 
rechargeable battery and charging system (CPT Code C1820) and insertion or replacement of peripheral or 
gastric neurostimulator pulse generator or receiver, direct or inductive coupling (64590). You asked the Plan to 
pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says 
this service is not covered. The Plan must follow Medicare rules. We looked at the file and Medicare rules. 
Based on this information, we decided that Medicare rules for coverage of the services have not been met. 
Medicare excludes the use of a sacral nerve stimulator for urinary incontinence in the event a member has a 
diagnosis of urinary obstruction. Therefore, we decided that the Plan does not have to pre-approve generator, 
neurostimulator (implantable), with rechargeable battery and charging system (CPT Code C1820) and insertion 
or replacement of peripheral or gastric neurostimulator pulse generator or receiver, direct or inductive coupling 
(64590).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on June 22, 2020 
and billed under code 92014. 
 
You asked the Plan to pay for code 92014. You say that this service should be paid by the Plan. The Plan 
denied your request. The Plan says Current Procedural Terminology (CPT) code 92014-25-57 (1 Unit) remains 
not supported. The billed evaluation and management code and the use of the -57 modifier to indicate the 
decision for surgery and/or perform a 90-day global service was made during the preoperative period of a 
major surgical procedure (or 90-day global period)  and cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, the claim submitted cannot be paid as 
billed for code 92014 due to its relationship previous services billed. Medicare coverage criteria are not met.  
Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on 
June 22, 2020 and billed under code 92014.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional twelve (12) physical therapy visits. 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not 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 services. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the documentation does not support that the unique skills of a 
professional therapist are required for 12 additional physical therapy visits. We looked at this physician's 
review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 
the services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional 
twelve (12) physical therapy visits.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a provider visit (99214) on May 21, 2020. 
 
You asked the Plan to pay for a provider visit. You say that this claim should be reconsidered. The Plan denied 
your request. The Plan says rules for payment have not been met. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on May 6, 2020. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for a provider visit (99214) on 
May 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for guided tissue regeneration (D4266) bone replacement graft 
for ridge preservation, teeth 5 and 12 (D7953) provided September 4, 2019. 
 
You asked the Plan to pay for the dental services. You say that if they hadn't lied to you, you wouldn't have 
consented to this procedure and you wouldn't be stuck with this installment payment plan for one year. The 
Plan denied your request. The Plan says these services are not covered under the plan 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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for guided 
tissue regeneration (D4266) bone replacement graft for ridge preservation, teeth 5 and 12 (D7953) provided 
September 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for office visits you had with a rheumatologist 
on August 24, 2020, and September 10, 2020. 
 
You asked the Plan to waive the copayments for the rheumatology visits. You say that this doctor prescribed 
you inappropriate medications, so you should not have to pay these copayments The Plan denied your request. 
The Plan says you were charged these copayments 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 $35 
copayment for specialist visits.  
 
You have been asked to pay a $35 copayment for the rheumatology visits. The rheumatology visits fall within 
the specialist visits 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. These copayments apply regardless of your satisfaction with the care you received. Therefore, we 
decided that the Plan does not have to waive the copayments for office visits you had with a rheumatologist on 
August 24, 2020, and September 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on June 17, 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 Current Procedural Terminology (CPT) code 66984 79 LT (1 unit) remains not 
supported. The submitted medical records do not indicate that extracapsular cataract removal with insertion of 
intraocular lens prosthesis (1 stage procedure), manual or mechanical technique; without endoscopic 
cyclophotocoagulation was performed; therefore, the billed service cannot be verified. It is noted that multiple 
attempts were made to contact the provider for additional information.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes and when necessary provide specific medical record 
documentation to support the services billed. We find that code 66984 79 LT (1 unit) is not supported in the 
medical record. Specifically, the records provided do not clearly reflect the services billed were performed as 
described by the CPT code. Medicare rules for coverage of this service have not been met. Therefore, we 
decided that the Plan does not have to pay for physician services provided to the enrollee on June 17, 2020.
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 stay is medically necessary. The Plan 
denied your request. The Plan says the stay 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 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. The 
documentation does not support that an additional 25 days of hospitalization are reasonably expected for the 
enrollee in this case. 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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided from January 10, 2020, through 
January 11, 2020. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the member was enrolled in hospice at the time of services. The Plan states per Medicare 
guidelines, the member's services should be billed under Original Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. The 
member was enrolled in Hospice from April 1, 2018, through May 5, 2020. Therefore, we decided that the Plan 
does not have to pay for the services provided from January 10, 2020, through January 11, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy services. 
 
You asked the Plan to pre-approve the additional physical therapy services. You say that you would like 
reconsideration because the services are necessary for the member to continue to improve their range of motion 
and manage their pain long term. The Plan denied your request. The Plan says the notes report no pain and that 
the member is able to complete exercises without issue. 
 
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 physical therapy services. 
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found the documentation does not support that 
the enrollee has continued pain and mobility difficulties that are interfering with her functional status. 
 
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 physical therapy services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve additional physical therapy services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the shoulder surgery coded as 29820, 29821, 29827 and 
29823. 
 
You asked the Plan to pre-approve the shoulder surgery. You say that the proposed left shoulder arthroscopy is 
both warranted and medically necessary in the treatment and management of the enrollee's left shoulder 
injuries. The Plan denied your request. The Plan says the records do not support that the requested services are 
reasonable and medically necessary. 
 
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 shoulder surgery. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the MRI does not show significant rotator cuff pathology. There is tendonitis on 
multiple tendons without significant tearing pathology. There is no clear correlation between the physical exam 
and imaging studies to justify all the surgical codes listed. The scope should be approved as the patient failed 
conservative treatment over time. However, the codes 29828, 29822, 29807, 29824 and 29826 cannot be 
approved as they are not supported by findings on the imaging studies. 
 
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 shoulder surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the shoulder surgery coded as 29820, 29821, 29827 and 29823.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Low Dose Computed Tomography (LDCT) Lung 
Cancer Screening (G0297) provided July 6, 2020. 
 
You asked the Plan to pre-approve the LDCT Lung Cancer Screening. You say that the test was medically 
necessary. The Plan denied your request. The Plan says rules for coverage were not met. 
 
The Plan must follow Medicare rules. Medicare rules say that LDCT Lung Cancer Screenings are covered for 
enrollees that are Ages 55-77 years.  
 
We looked at the file and Medicare rules. The enrollee was 83 years old at the time of service. Based on this 
information, we decided that Medicare rules for coverage of the LDCT Lung Cancer Screening have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a Low Dose Computed Tomography 
(LDCT) Lung Cancer Screening (G0297) provided July 6, 2020.
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 stay is medically necessary. The Plan 
denied your request. The Plan says the stay 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 there is no documentation provided necessitating admission to a LTACH. The 
enrollee's primary condition has stabilized. The enrollee will be on intravenous (IV) antibiotics daily through 
January 14, 2021, and has had a decline in LOF from baseline, both needs can be met in LLOC. The enrollee 
does not require services at the LTACH that are not available at the acute care hospital where she is currently 
receiving care. There are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting being offered by the health plan. The requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished 
safely and effectively only on an inpatient basis. 
 
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: 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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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 the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for COVID 19 infection. Medical conditions are stable. There are no medical needs requiring 
inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record documents a need for physical and occupational 
therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable 
expectation that this patient 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on August 7, 2019. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the member was enrolled in hospice at the time of services. The Plan states per Medicare 
guidelines, the member's services should be billed under Original Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit 
for the dates of service at issue in this appeal. The member was enrolled in Hospice from August 2, 2019, 
through September 24, 2020. Therefore, we decided that the Plan does not have to pay for the services provided 
on August 7, 2019.