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

 
We decided that the Plan does not have to pay more for the crown (D2740) provided on July 7, 2020. 
 
You asked the Plan to pay more for the dental service. You say that you understand that insurance companies 
negotiate with providers for favorable fees but an allowed amount of $452.50 for a crown is unreasonable. You 
say that the mixed messages you received from the Plan and an in network provider lead you to believe it is not 
factual. The Plan denied your request. The Plan says crowns are covered with a 50% coinsurance after the $100 
deductible is met. The Plan says there is a $100 deductible The Plan says that the provider in this case is out of 
network. The Plan says that out of network providers can bill you for the difference between the charged 
amount and the amount that the Plan pays. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and crowns are listed as a covered 
service, the $100 deductible must be met before the plan will apply payment for the crown. The allowed 
amount for the crown is $452.50. After the $100 deductible is applied, the Plan applied the 50% coinsurance to 
$352.50 resulting in a payment of $176.25. Therefore, we decided that the Plan does not have to pay more for 
the crown (D2740) provided on July 7, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that the enrollee is supposed to be discharged 
from the hospital but cannot be sent home yet and needs SNF care for further rehabilitation. The Plan denied 
your request. The Plan says there is no documentation supporting the need for services in a SNF. 
 
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 there are no identifiable skilled 
nursing service needs. While there are identifiable skilled therapy service needs, the enrollee does not require 
skilled nursing or therapy services on a daily basis.  The enrollee 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 skilled nursing facility (SNF) admission.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram services provided on June 11, 2020. 
 
You asked the Plan to pay for the electrocardiogram 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 separately 
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 93010 is electrocardiogram, routine ECG with at least 12 
leads; interpretation and report only. 
 
We find that CPT code 93010 is not supported in the medical record. Specifically, payment is not separately 
made to any provider or supplier other than the facility for services furnished to the beneficiary for surgery. 
The facility must furnish all necessary covered services to the enrollee either directly or under arrangements 
made between the facility and outside vendors. The enrollee received the services in preparation for surgery at 
the facility. Based on this information, we decided that Medicare rules for coverage of the electrocardiogram 
services have not been met. Therefore, we decided that the Plan does not have to pay for the electrocardiogram 
services provided on June 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 17, 2020.

You asked the Plan to pay for the seat lift mechanism. You say that you had your prescription and you didn't know you needed to get a prior authorization. The Plan denied your request. The Plan says a prior authorization is required per the EOC.

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 DME is not a covered service. 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 August 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on August 28, 2020.
You asked the Plan to pay for the dental service. You say that you have been seeing this provider for years. You also say that claims have always been covered. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that dental services that you receive 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, dental services that you receive out of network are not covered. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on August 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the criteria for coverage of LTACH care
have been met. The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have
not been met.

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 still requires acute hospital level of care services and is receiving appropriate care at the present acute
care hospital. The enrollee does not require services at the LTACH that are not available at the acute care
hospital where he 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 long-term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Vitamin D assay testing provided on July 23, 2020. 
 
You asked the Plan to pay for Vitamin D testing. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of payment for this test is correct, because Medicare 
considers this testing non-covered screening.  
 
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, Vitamin D testing, is considered a screening test by Medicare. Medicare does 
not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for 
Vitamin D assay testing provided on July 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tumor profile testing. 
 
You asked the Plan to pre-approve the requested testing. The Plan denied your request. The Plan says the 
records do not show why the test was ordered. 
 
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. In this case, the medical records do not indicate that the results of 
testing will be used to determine a specific treatment strategy, or why the test was being performed. Based on 
this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pre-approve tumor profile testing.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services (90837) provided on April 10, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for OON psychotherapy services. You say that this service was provided in good 
faith. The Plan denied your request. The Plan says this service was not authorized. 
 
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 psychotherapy services (90837) provided on 
April 10, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a SNF admission. 
 
You asked the Plan to pre-approve the SNF admission. The Plan denied your request. The Plan says the criteria 
for admission to SNF have not been met. 
 
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 you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily 
skilled nursing needs that requires the specialized skill, knowledge, and judgment of a skilled professional 
nurse. You do not have daily skilled therapy needs that requires the specialized skill, knowledge, and judgment 
of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an 
inpatient basis in a SNF 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 a SNF admission.
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 
August 4, 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 billed are not payable. 
 
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 August 4, 2020, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forskilled nursing facility (SNF)care provided on July 16, 2020, through August 15, 2020.You asked the Plan to pay forSNF care. You say that the service is medically necessary.The Plan denied your request. The Plan says the services were not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary does not require skilled nursing or therapy services on adaily basis and there are no identifiable skilled therapy service needs.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 care have not been met. Specifically, the beneficiary does not require daily skilled services.Therefore, we decided that the Plan does not have to pay forskilled nursing facility (SNF) care provided on July 16, 2020, through August 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rest home visit services provided on March 31, 2020, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the rest home visit 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 rest home visit services provided on March 31, 
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 the foot x-ray provided on September 23, 2020. 
 
You asked the Plan to pay for the foot x-ray (73630). You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says this claim cannot be paid as submitted. 
 
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 have confirmed that code the 
foot x-ray has a bundled relationship with code 73650 and cannot be paid as billed. This code cannot be paid as 
a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the foot x-ray provided on September 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says there is no complex care need that require this 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 appears to be more stable and improving with current treatment but 
requires additional short-term acute care which can be safely completed at the current facility. The enrollee 
does not require LTACH services that are not already available at the current facility. There are no services at 
the LTACH that the enrollee requires that are not already available and covered at the current facility. 
Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer 
may be considered soon when treatment has completed and when appropriate for a lower level of care. 
 
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 admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not support the criteria for IRF care has been met. 
 
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 enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
current medical status does not require intensive physician and nursing monitoring or management in an IRF. 
The enrollee may benefit from additional physical therapy but the documentation does not support that the 
enrollee's functional status with ambulation of 140 feet supervision and transfers with supervision requires this 
therapy on an intensive IRF level. 
 
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency department visit (99285) 
provided August 27, 2020. 
 
You asked the Plan to waive the copayment for the emergency visit. You say that you feel that you should not 
have to pay the copay because you went to the emergency room and was admitted into the hospital. The Plan 
denied your request. The Plan says this claim was processed with the correct copayment applied per the 
Evidence of Coverage. 
 
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 $50 for 
each emergency room visit.  
 
You have been asked to pay $50 for the emergency visit. The plan has confirmed that you were in observation. 
You pay for emergency room services even when held in observation. The emergency visit falls 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 emergency 
department visit (99285) provided August 27, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit for the evaluation and management of an 
established patient provided on July 7, 2020, by an OON provider. 
 
You asked the Plan to pay for the home visit. You say that authorization should not be needed under 
telemedicine for payment of needed services. The Plan denied your request. The Plan says the service was 
rendered by an OON provider. The Plan also says that the service was not approved in advance. 
 
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 
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 home visit for the evaluation and management 
of an established patient provided on July 7, 2020, by an OON provider.