Persius/hicric huggingface dataset:
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 you need to get back on your feet so that you can get 
back to Ohio. You say that you cannot walk and the place you are currently in is not helping you. The Plan 
denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the 
enrollee could receive care in another setting. 
 
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 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 
was admitted for aspiration pneumonia. The enrollee's medical problems are stable. There are no complex 
nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee 
has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. There is not a reasonable expectation that this enrollee 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 debridement (11043 and 11046) provided on June 14, 2021. 
 
You asked the Plan to pay for debridement (11043 and 11046). You say that the enrollee underwent 
debridement of right foot and placement of skin graft. You say that payment of the denied code should be 
reconsidered. The Plan denied your request. The Plan says procedure codes 11043 and 11046 are not supported 
by the medical records 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, the CPT Code Manual definition of code 11043 is debridement, muscle and/or fascia (includes 
epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less. The CPT Code Manual 
definition of code 11046 is debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous 
tissue, if performed); each additional 20 sq cm, or part thereof (List separately in addition to code for primary 
procedure). 
 
We asked our coder 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 debridement (11043 and 11046). Our reviewer says that CPT 
codes 11043 and 11046 are not supported. Our reviewer found that the operative note does not support the 
debridement of muscle and/or fascia, first 20 sq cm or less or each additional 20 sq cm. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of debridement (11043 and 11046) have not been met. Therefore, we decided that 
the Plan does not have to pay for debridement (11043 and 11046) provided on June 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for angiography services (procedure code 75716) provided to the 
enrollee on November 24, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied code is inclusive to another code. 
 
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 75716 is "Angiography, extremity, bilateral, radiological 
supervision and interpretation." 
 
We asked our coder 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 services at issue in 
this case were not supported by the medical records. Our reviewer found when reporting radiological 
supervision during the same session as an intervention, documentation would support an initial diagnostic study 
that diagnoses the patient's pathology and to plan the intervention. In this case, the documentation support a 
previous arterial duplex study was performed and suggests peripheral artery disease (PAD). To cite the operative report "Patient had an arterial duplex study which suggested severe PAD.  A diagnostic angiogram is 
necessary to determine the exact location and severity of disease and to determine whether intervention is 
warranted." CPT 75716 cannot be verified as a separate procedure from the intervention. 
 
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 angiography services (procedure code 75716) provided to the enrollee on November 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on December 4, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says a modifier was not billed on the claim to represent the services as separate and distinct. 
 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 71045 
is a column II code to column I code 32555. 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 imaging services provided to the enrollee on December 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid (V5261) provided on November 12, 2021. 
 
You asked the Plan to pay for the hearing aid. You say that you trust this provider and this brand, and you feel 
that your hearing benefits are confusing because you have out-of-network coverage for all of your medical 
benefits. The Plan denied your request. The Plan says hearing aids are only covered when they are purchased 
through the Plan's specified routine hearing vendor network. The provider in this case is not part of the required 
network; therefore, the hearing aids are denied. 
 
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 through the Plans specified routine hearing 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. Based on this information, we decided that the Plan's rules for coverage of the hearing aid 
have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aid (V5261) 
provided on November 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided 
by a participating provider on December 16, 2021. 
 
You asked the Plan to pay for a comprehensive periodontal evaluation. You say that this should be covered. 
The Plan denied your request. The Plan says the rendered dental service is not a covered dental benefit. 
 
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 pay for a 
comprehensive periodontal evaluation (D0180) provided by a participating provider on December 16, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay more for the crown (D2790). We decided that the Plan does not have to 
pay more for the core buildup, including any pins when required (D2950).  
 
You asked the Plan to pay more for the crown (D2790) and core buildup, including any pins when required 
(D2950) provided on October 6, 2021, and November 3, 2021. You say that you would like the insurance 
company to pay an additional $26.00 to the dentist. The Plan says that the cost share is correct. 
 
We decided that the Plan has to pay more for the crown (D2790).  
 
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. 
 
We looked at the file and Medicare rules. The documentation shows that you were charged more than 50% of 
the maximum approved fee for the crown (D2790). The 2021 Evidence of Coverage (EOC) states that you are 
responsible for a 50% coinsurance for major restorative services, including crowns. The EOC does not specify 
only certain materials are covered, nor does it say that you will be charged more than a 50% coinsurance for 
certain dental services. Therefore, we decided that the Plan has to pay 50% of the maximum approved fee for 
the crown (D2790).  
 
We also decided that the Plan does not have to pay more for the core buildup, including any pins when 
required (D2950). 
 
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, you are responsible for a 50% 
coinsurance for major restorative services, including crowns, onlays, and associated substructures services. 
Therefore, we decided that the Plan does not have to pay more for the core buildup, including any pins when 
required (D2950). 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve out-of-network acupuncture. You say that you have breast cancer, and this 
doctor offers alternative treatment to treat cancer. The Plan denied your request. The Plan says in-network 
providers are available. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
  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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
acupuncture to be provided by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on August 30, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says CPT 64415 is included in the CPT 01830; therefore, it cannot be separately reimbursed. 
 
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 64415 is "Injection(s), anesthetic agent(s) and/or steroid; 
brachial plexus." 
 
We asked our coder 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 services at issue in 
this case were not supported by the medical records. Our reviewer found the documentation includes a 
handwritten anesthesia report, which documents a "superaclavicular block", which does not meet criteria for a 
separate procedure from anesthesia services provided.  
 When performing a post-operative pain injection in addition to anesthesia services, documentation must 
support this service was requested by the operating physician, as well as, injection is for post operative pain 
management. In this case, this procedure cannot be confirmed. 
 
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 imaging services provided to the enrollee on August 30, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room visit (99285) provided on September 10, 
2021. 
 
You asked the Plan to pay for an emergency room visit. You say that this was an independent visit. The Plan 
denied your request. The Plan says this was billed on the same day as a minor procedure without a modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that modifier -25 is used to facilitate billing of 
evaluation and management services on the day of a procedure for which separate payment may be made. 
 
We looked at the file and Medicare rules. The emergency department visit at issue was billed on the same day as a minor procedure, 12013, but was not billed with modifier -25. Based on this information, we decided 
that Medicare rules for coverage of an emergency room visit have not been met. Therefore, we decided that the 
Plan does not have to pay for an emergency room visit (99285) provided on September 10, 2021.
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 you continue to require acute care services including high flow oxygen and 
intravenous medications. You continue to receive acute care services, and these have not been denied. The 
medical record does not indicate that you require services that he is not currently receiving but that would be 
available at the LTACH facility. 
 
 
 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the medical eye exam (9200r) provided on 
October 6, 2021. 
 
You asked the Plan to waive the copayment for the eye exam. You say that this was a routine eye exam and 
should have a $0 copayment. The Plan denied your request. The Plan says a medical diagnosis was made 
during this eye exam. That means that this became a medical eye exam, which requires a $35 copayment. 
 
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 Medicare-covered exams to diagnose and treat diseases of the eye.  
 
You have been asked to pay a $35 copayment for the eye exam. The eye exam in this case included a medical 
diagnosis and counseling. 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 medical eye exam 
(9200r) provided on October 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lung cancer genetic testing panel provided on August 26, 
2021. 
 
You asked the Plan to pay for the lung cancer panel. You say that this is medically necessary testing, and the 
number of genes tested should not be limited. At the very least partial payment should be made for these 
services. The Plan denied your request. The Plan says this testing was billed with an inappropriate POS code. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lung cancer panel have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the lung cancer genetic testing panel provided on August 26, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted ambulance service (A0999) provided on August 
9, 2021. 
 
 
 You asked the Plan to pay for the ambulance service. You say that this should be covered as this is the 
ambulance provider that transported you to the hospital. The Plan denied your request. The Plan says the 
enrollee was transported to the emergency department by the basic life support (BLS) provider. The Plan also 
says there is no agreement between the advanced life support (ALS) and BLS providers. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for advanced life support (ALS), in 
accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-
Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the 
services are furnished under a contract with a qualified basic life support (BLS), the provision of medically 
necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow 
the volunteer ambulance company to bill for the transport or BLS services.  
 
The Plan has confirmed that ALS ambulance provider does not have a contract with the volunteer ambulance 
company that provided the transport services. Therefore, we decided that the Plan does not have to pay for the 
unlisted ambulance service (A0999) provided on August 9, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you do not agree with the denial, and you are 
requesting SNF care. The Plan denied your request. The Plan says you have exceeded your Plan benefit limit 
for SNF care. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from January 10, 2022, 
through April 20, 2022. The Plan has covered 100 days of SNF care. 
 
 
 
 
 
 
 
 Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve skilled nursing facility (SNF) care.