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

 
We decided that the Plan does not have to pre-approve a consultation and treatment to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve a consultation and treatment to be provided by an OON provider. You say 
that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that 
are able to provide these services. Therefore, coverage criteria have not been met. 
 
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 
a consultation and treatment to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services provided on 
August 1, 2022, to August 2, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital services. You say that you are disputing the 
share cost. The Plan denied your request. The Plan says this cost sharing was charged 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 $275 
copayment per day for days 1 to 6 for inpatient hospital care. This inpatient hospital stay lasted 2 days, 
resulting in a copayment amount of $550 ($275 per day for days 1 to 6). 
 
You have been asked to pay $275 copayment per day for days 1 to 6 for inpatient hospital services. This 
item/service falls within the inpatient hospital 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 inpatient hospital services provided on August 1, 2022, to August 2, 2022.
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 you would benefit from inpatient rehabilitation 
services due to your medical complexity. The Plan denied your request. The Plan says your needs can be met at 
a lower level of care such as skilled nursing facility (SNF), home with home health services or home with 
outpatient 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 there are no complex nursing or rehabilitation needs. While you have a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 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: 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 the enrollee requires aggressive therapy to regain 
functional mobility to return to previous level of independence. The Plan denied your request. The Plan says 
based on Medicare guidelines, the requested IRF services do not meet the requirements for approval. 
 
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 that the complexity of the enrollees nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the 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: 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 that its critical for your recovery to be transferred to 
an IRF for physical and occupational therapy services you need each week. You say that you will not be able to 
progress in a home health setting or in a skilled nursing facility. The Plan denied your request. The Plan says an 
IRF admission is not medically necessary, and the care you need can be provided in a skilled nursing facility. 
 
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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 3, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with an office setting POS 
code. The records do not support that the sample was taken in an office setting. Therefore, we decided that the 
Plan does not have to pay for lab services provided on December 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 22, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. 
 The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory 
testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on June 22, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36416 billed for date of service September 7, 
2022. 
 
You asked the Plan to pay for procedure code 36416. You say that this claim should be reprocessed. The Plan 
denied your request. The Plan says procedure code 36416 is considered bundled and 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 procedure code. 
 We find that procedure code 36416 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 36416 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 36416 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 36416 billed for date of service September 7, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 7, 2022. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 lab services 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 lab services provided on July 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 38220-59, 20936, and 20930 billed for date 
of service June 8, 2022. 
 
You asked the Plan to pay for procedure codes 38220-59, 20936, and 20930. You say that you have provided 
medical records to support payment. The Plan denied your request. The Plan says code 38220-59 is bundled 
with code 22610.  The Plan also says that codes 20936 and 20930 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, we have confirmed that code 
38220-59 is a column II code to column I code 22610 with a modifier indicator of 0. The column II code is 
therefore not payable. In addition, Medicare rules state that codes with a status indicator of B are not separately 
payable under the Medicare Physician Fee Schedule. Both codes 20936 and 20930 have a status indicator of B. 
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 38220-59, 20936, and 20930 billed for date of service June 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 16 miles, for a total of 66 miles. 
 
You asked the Plan to pre-approve an additional 16 miles, for a total of 66 miles. You say that due to the fact of 
the location of here you live, most providers are over 50 miles away. The Plan denied your request. The Plan 
says the requested service is covered under the Plan, but the requested amount exceeds the limit listed by the 
Plan. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 50 miles for each one-way trip trips per year.  
 
 
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve an additional 16 miles, for a total of 66 miles.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 16, 2022, to 
April 11, 2022. 
 
You asked the Plan to pay for the home health 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 as billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the claim submitted, the file and the Medicare rules. Medicare rules say for all enrollees receiving 
home health services in 2021 whose services will continue in 2022, the home health agency shall submit an 
NOA with a one-time artificial admission date corresponding to the From date of the first period of 
continuing care in 2022. Based on this information, we decided that Medicare rules for completing the claim 
for home health services have not been met. Specifically, the file shows that the denied claim was submitted 
with an admission date of December 14, 2021, which does not match the admission date on the NOA. 
Therefore, we decided that the Plan does not have to pay for the home health services provided from March 16, 
2022, to April 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain/ceramic crown (D2740). 
 
You asked the Plan to pre-approve the dental services. You say that you got a crown on November 27, 2019, 
and it fell out a couple of weeks ago. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service November 27, 2019. 
Therefore, we decided that the Plan does not have to pre-approve a porcelain/ceramic crown (D2740).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
January 17, 2022, to January 27, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the DRG was updated.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 196. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pay for the inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that based on the provided documentation including the findings above, there was insufficient support found in 
the notes for the diagnosis of acute and chronic respiratory failure with hypoxia (J96.21) or for the diagnosis 
of acute and chronic respiratory failure with hypercapnia (J96.22) as there was insufficient evidence of a 
worsening beyond her baseline chronic respiratory status. Therefore, the original DRG 196 (INTERSTITIAL 
LUNG DISEASE WITH MCC) is not supported and the revised DRG 197 (INTERSTITIAL LUNG DISEASE 
WITH CC) would be more appropriate for this admission.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from January 17, 2022, to January 27, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lower 
extremity without contrast. 
 
You asked the Plan to pre-approve the MRI. You say that the enrollee has lumbar radiculopathy with right side 
and left side sciatica. The Plan denied your request. The Plan says there was no reference to joint complaint or 
joint pain in the medical records; therefore, the MRI does not meet the Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI. Our reviewer says that the 
MRI of the lower extremity without contrast is not medically necessary. Our physician reviewer found the 
enrollee's last encounter was September 29, 2022, at which time bilateral sciatica was noted and due to 4 
months of conservative therapy without relief an MRI lumbar spine was ordered and should be approved. 
Physical exam of the extremities was normal with normal range of motion and normal ambulation. No plan for 
any imaging of the hips or lower extremities was detailed during the last documented encounter. The medical 
necessity of MRI of either lower extremity has not been demonstrated in the records provided. 
 
  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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of the lower extremity without contrast.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve occlusal orthotic device (D7880). 
 
You asked the Plan to pre-approve occlusal orthotic device (D7880). You say that this is a medical necessity 
and not just a dental issue. The Plan denied your request. The Plan says the members device is being used to 
treat TMJ and therefore this denied and as such is not a covered benefit under Medicare. Therefore, this request 
is denied. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only 
when the condition or symptom is medical in nature. The treatment must also be medically reasonable and 
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 occlusal orthotic device (D7880) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve occlusal orthotic device (D7880).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat hyaluronan injection services. 
 
You asked the Plan to pre-approve repeat hyaluronan injection services. You say that this is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a repeat series of hyaluronan knee injections are 
necessary if there was significant improvement in pain and functional capacity achieved with the prior series of 
injections using a standardized assessment. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of repeat hyaluronan injection services have not been met. Specifically, the medical records submitted 
do not indicate that there was a follow-up appointment at any time since the last injection service to 
demonstrate the effects of the first series of injections. Therefore, we decided that the Plan does not have to 
pre-approve repeat hyaluronan injection services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for Medicare Part B drugs and CT scan were 
provided on July 19, 2022. 
 
You asked the Plan to waive the cost share for Medicare Part B drugs and CT scan. You say that you are 
disputing the share cost. The Plan denied your request. The Plan says this cost sharing was charged 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 20% 
coinsurance for Medicare Part B prescription drugs. The allowed amount of these drugs total $48.42, resulting 
in a total coinsurance amount of $9.68. Your contract with the Plan clearly says that you must pay $275 for 
outpatient hospital services. 
 
You have been asked to pay 20% coinsurance for Medicare Part B drugs and $275 copayment for CT scan. 
These items/services fall within the Medicare Part B prescription drugs and outpatient hospital services benefit categories. 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 cost share for Medicare Part B drugs and CT scan were 
provided on July 19, 2022.