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

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the admission is 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 in the Medicare rules section 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 these services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the records show that you were admitted 
to the hospital after a fall at home. You had a new stroke, broken ribs, and a broken left hip. You were 
medically stabilized and have been receiving skilled therapy in an inpatient rehabilitation facility (IRF). You 
have tolerated the inpatient rehabilitation services and continued to improve with daily skilled nursing and 
daily skilled therapy. There is no indication that transfer to a SNF is required. There are no services that you 
require at the SNF that are not available at the current IRF. The SNF admission is not medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88305) provided September 23, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the code billed is 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. 
 
We find that CPT code 88305 is not supported in the medical record. Specifically, the service has a 
professional component / technical component indicator of 1. Payment for this service is included in the facility 
payment. Based on this information, we decided that Medicare rules for coverage of the lab services have not 
been met. Therefore, we decided that the Plan does not have to pay for lab services (88305) provided 
September 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided to the enrollee on May 13, 2021.
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your
request. The Plan says Medicare billing criteria were not met. We overturned the Plans denial stating the
services were originally ordered by a Plan provider. The Plan requested a reopen and provided additional
information. The Plan states this was a billing and coding denial and not a medical necessity denial. The Plan
states that this drug testing denied because the provider coded the claim incorrectly. The records do not include
definitive laboratory results for 22 or more drug classes to support the coding criteria for the code billed on date
of service. There was a total of 15 drug classes counted from the laboratory results received.
The Plan is correct in this case. 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 records
provided do not support the services listed on the claim. Medicare rules for coverage of this testing have not
been met. Therefore, we decided that the Plan does not have to pay for drug testing provided to the enrollee on
May 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Oxycodone tablet. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Oxycodone tablet is a self-administered drug and not covered under the enrollee's 
Part B benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Oxycodone tablet.  Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided to the enrollee on May 13, 2021.
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your
request. The Plan says the records do not support the services billed. We overturned the Plans denial. The
Plan requested a reopen and provided documentation to show only 18 drug classes had been billed, which
required a different coding option for the claim.
The Plan is correct in this case. 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 records
provided do not support the services listed on the claim. Medicare rules for coverage of this testing have not
been met. Therefore, we decided that the Plan does not have to pay for drug testing provided to the enrollee on
May 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fixed partial denture sectioning (D9120), guided tissue regeneration - resorbable barrier, per site (D4266), bone replacement graft for ridge preservation - per site (D7953) provided August 5, 2021.
You asked the Plan to pay for the fixed partial denture sectioning, guided tissue regeneration and bone replacement graft. You say that you would like the services covered. The Plan denied your request. The Plan says these services are not covered under your 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 the fixed partial denture sectioning (D9120), guided tissue regeneration - resorbable barrier, per site (D4266), bone replacement graft for ridge preservation - per site (D7953) provided August 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5298) purchased on July 16, 2021, from 
an out-of-network provider. 
 
You asked the Plan to pay for out-of-network hearing aids. You say that you feel the hearing aids from this 
provider are better than the competitors. The Plan denied your request. The Plan says hearing aids are not 
covered through this provider. Hearing aids must be purchased through the Plan's contracted routine hearing 
vendor network as specified in the contract. 
 
  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are purchased from the specified vendor network.  
 
We looked at the file and the Plan's rules. The provider in this case is not part of the Plans routine hearing 
vendor network as specified in the contract. Based on this information, we decided that the Plan's rules for 
coverage of out-of-network hearing aids have not been met. Therefore, we decided that the Plan does not have 
to pay for the hearing aids (V5298) purchased on July 16, 2021, from an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 16, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered.  
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, 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 the laboratory 
services provided on September 16, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a physical therapy visit provided on 
November 2, 2021. 
 
You asked the Plan to waive the copayment for a physical therapy visit. You say that you had physical therapy 
after having a total knee replacement. You also say that the physical therapy visit should be included in the 
surgery charges. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
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 $30 
copayment for an in-network physical therapy visit.  
 
 The record shows that a physical therapy visit is a separate service from outpatient surgery. You have been 
asked to pay a $30 copayment for a physical therapy visit. A physical therapy visit falls within the Outpatient 
Rehabilitation Services 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 a physical 
therapy visit provided on November 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee can be treated at lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 patient does not require treatment by multiple therapies and an intensive rehabilitation therapy program. While the patient has a need for physical or occupational therapy, there is no 
documentation of 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on September 21, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 23430 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 23430 (repair biceps tendon) and 23472 (reconstruction 
shoulder joint). Code 23430 is a column II code with a modifier indicator of 1 when billed with column I code 
23472. Code 23430 was not billed with an appropriate modifier to allow for separate payment. The file does 
not support the billing of the -59 modifier as a separate and distinct procedural service. Therefore, we decided 
that the Plan does not have to pay for the surgical services rendered on September 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services billed to the enrollee for April 15, 2021.
You asked the Plan to pay this claim. You say that this service should e covered by the Plan. The Plan denied
your request. The Plan says this service was previously paid. We overturned the Plans denial. The Plan
requested a reopen and provided additional information. The Plan states this claim denied as a duplicate
because the previously paid for this service under another claim. The Plan provided a copy of that previously
paid claim.
The Plan is correct in this case. 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 Plan has
confirmed that these services were previously paid. Based on this information, we decided that Medicare rules
for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for lab
services billed to the enrollee for April 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the cost share applied to the deductible for elective
outpatient services provided on March 23, 2021.
You asked the Plan to waive or reduce this cost share. You say that you do not believe this service should be
applied to the deductible. The Plan denied your request. The Plan says this service was applied correctly based
on the Plan contract agreement and the services provided. We overturned the Plans denial. The Plan
requested a reopen and stated that we did not apply the correct contract language. The Plan says that the
records show code 11620 is a surgical code, subject to the deductible and cost share once the deductible is met.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information. Your contract with the Plan says that there is $750 deductible which applies to and
then a $125 copayment for outpatient surgery. The Plan has followed Medicare rules by clearly disclosing in
the contract that there is $750 deductible. This cost sharing is a contractual obligation that had not been met at
the time of service. Therefore, we decided that the Plan does not have to waive or reduce the cost share applied
to the deductible for elective outpatient services provided on March 23, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on February 3 to March 4, 
2021. 
 
You asked the Plan to pay for home health services. You say that the services at issue were a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules say that to report HH visits, the HHA reports one of the 
HCPCS codes listed in the Medicare rules section to represent a visit by each HH care discipline. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, the claim includes billed code S9131. Code 
S9131 is not a valid Medicare code for home health physical therapy. Therefore, we decided that the Plan does 
not have to pay for home health services provided on February 3 to March 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient visit services (99213) provided on November 
3, 2021. 
 
You asked the Plan to pay for code 99213. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed.  
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 99213 
is a column II code to column I code G0439. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 outpatient visit services (99213) provided on November 3, 
2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided the Plan does not have to pay for radiation treatment provided to the enrollee on February 10,
2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the Medicare billing criteria were not met. We overturned the Plans denial for
insufficient information in the case file. The Plan requested a reopen and provided additional information. The
Plan states that this claim denied because the service must be reviewed under the Original Medicare Benefits.
This service is allowed only in clinical research study. The Plan contract a clinical research study must be
approved by Medicare. If the enrollee is not approved for the study, the enrollee will be responsible for paying
all the costs related to and provided during the study. Original Medicare pays most of the cost of the covered
services you receive as part of the study. After Medicare has paid its share of the cost for these services, the
Plan will also pay for part of the costs. The Plan pays the difference between the cost-sharing in Original
Medicare and the cost-sharing enrollees pay as members of this Plan.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
Original Medicare pays for costs incurred during a clinical trail. If the enrollee was an approved participant in
the clinical trial, Original Medicare will address those costs first and the Plan will address any costs remaining
after that review. If the enrollee was not an approved participant, the enrollee pays all of the costs incurred
during the clinical trial. Therefore, we decided that until Original Medicare addresses this claim, the Plan does
not have to pay for radiation treatment provided to the enrollee on February 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a ranibizumab injection provided on 
October 19, 2021. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you were advised that the injection 
was 100% covered. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
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% 
coinsurance for Part B drugs.  
 
You have been asked to pay $318.47, which is 20% of the allowed amount for the injection ($1,592.36 allowed 
amount x 20% coinsurance = $318.47). The injection falls within the Medicare Part B Prescription Drugs 
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 coinsurance for a ranibizumab injection 
provided on October 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat-lift mechanism (E0627). 
 
You asked the Plan to pre-approve the seat-lift mechanism. You say that this item is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are met. 
 
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 seat-lift mechanism. Our reviewer 
says that the seat lift is not medically necessary. Our physician reviewer found the records do not show that the 
patient is completely incapable of standing from a chair in the home. The records show that the patient has the 
ability to ambulate. 
 
 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 seat-lift mechanism have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a seat-lift mechanism (E0627).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (88312 and 88305) provided on 
October 29, 2021. 
 
You asked the Plan to pay for codes 88312 and 88305. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT codes 88312 and 88305 are not supported in the medical record. Specifically, the records 
indicate that the member was an outpatient on the billed date of service. Payment for CPT codes 88312 and 
88305 is included in the payment to the facility and is the responsibility of the facility to any vendor.  Therefore, we decided that the Plan does not have to pay for the laboratory services (88312 and 88305) 
provided on October 29, 2021.