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

 
We decided that the Plan does not have to pay for the endodontic therapy (D3310) provided on November 24, 
2021. 
 
You asked the Plan to pay for the endodontic therapy. You say that you were not advised that the dentist was 
not in-network. The Plan denied your request. The Plan says this service is not a covered expense under your 
dental plan. The Plan also says that on November 15, 2021 you contacted the Plan to obtain a list of in-network 
providers, which was mailed to your address, however during that call you did not 
verify benefits. 
 
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 the 
endodontic therapy (D3310) provided on November 24, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hot or cold packs therapy (97010) provided on October 
14, 2021. 
 
You asked the Plan to pay for the hot or cold packs therapy (97010). You say that there is a valid authorization 
for this visit and the claim should be reprocessed for payment. The Plan denied your request. The Plan says 
CPT codes 97110, 97112, 97150, and G0283 were overturned. The Plan also says CPT code 97010 remains 
denied. 
 
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 97010 is application of a modality to 1 or more areas; hot 
or cold packs. 
  We find that CPT code 97010 is not supported in the medical record. Specifically, CPT code 97010 has a status 
indicator of B. This means that CPT code 97010 is considered bundled and not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the hot or cold packs therapy (97010) have not 
been met. Therefore, we decided that the Plan does not have to pay for the hot or cold packs therapy (97010) 
provided on October 14, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) provided to the enrollee from 
May 15, 2020, to June 9, 2020. 
 
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 provider has reported skilled services with the incorrect PDPM Health Insurance Prospective 
Payment System (HIPPS) Score. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
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 is insufficient to 
support a PT/OT function score of 10-23, or a nursing function score of 6-14. 
 
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 skilled nursing facility (SNF) provided to the enrollee from May 15, 2020, to June 9, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for injections of anesthetic or steroid agents (64447, 64450) provided on 
January 26, 2021. 
 
You asked the Plan to pay for injections of anesthetic or steroid agents. You say that the services at issue were 
a medical necessity for the enrollee. The Plan denied your request. The Plan says that rules for payment have 
not been met because the procedure codes at issue are inclusive to another billed code. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has denied this service stating that payment for CPT codes 
64447 and 64450 is included in the payment of CPT code 01480. The Plan has not forwarded any evidence that 
CPT code 01480 was billed on the same date of service. The Plan has not provided additional evidence to 
indicate why CPT codes 64447 and 64450 cannot be paid. It is the burden of the Health Plan to substantiate 
their denial with evidence. In this case, the Plans denial is not substantiated, so we must find in your favor. 
Therefore, we decided that the Plan has to pay for injections of anesthetic or steroid agents (64447, 64450) 
provided on January 26, 2021.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 19, 2021 by an 
out-of-network (OON) provider. 
 
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 the services were rendered by an out-of-network provider without prior authorization. 
 
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 had network providers 
available who could have provided 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 laboratory services provided on August 19, 
2021 by an out-of-network (OON) provider.
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 your health will be seriously harmed without IRF 
care. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says 
that the enrollee can safely receive the services needed in other settings. 
 
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 surgical repair of a hip fracture after a fall. 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided 
on December 16, 2021. 
 
You asked the Plan to pay for the comprehensive periodontal evaluation. You say that you only received an x-
ray on this date of service. You also say that when you were about to get the cleaning, you were advised that 
you needed a deep cleaning, but did not receive it. The Plan denied your request. The Plan says this service is 
not a covered benefit under your dental plan. 
 
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 the 
comprehensive periodontal evaluation (D0180) provided on December 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an electrocardiogram (ECG) and a 
cardiology specialist office visit provided on December 21, 2021. 
 
You asked the Plan to waive the copayments for an ECG and a specialist office visit. You say that you were 
referred to the cardiologist for clearance to proceed with another procedure, which was later determined you no 
longer needed. You also say that you should not have pay for this visit since you did not need the other 
procedure and did not need this appointment in the first place. 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 $10 
copayment for diagnostic testing, including ECGs. The Plan contract also says that enrollees must pay a $40 
copayment for a specialist office visit. The contract says if you receive other services during the office visit, 
other cost sharing may apply according to the benefit specific category. 
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$10 copayment for an ECG. An ECG falls within the Outpatient Diagnostic Tests and Therapeutic Services and 
Supplies benefit category. You have also been asked to pay a $40 copayment for a specialist office visit. A 
specialist office visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits benefit 
category. You have been asked to pay a total of $50 ($10 copayment + $40 copayment = $50). 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 copayments for an electrocardiogram (ECG) and a cardiology specialist office visit 
provided on December 21, 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 the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the documentation does not reveal evidence of 
complex wound care or other daily skilled nursing SNF need. The coccyx wound requires allevyn life foam 
applied every other day. Your functional level does not require skilled therapy services with the specialized 
skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary 
and reasonable treatment in a SNF. You do not require skilled nursing or skilled therapy services (or a 
combination of these services) on a daily basis in a SNF. As a practical matter, you do not require the necessary 
services on 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the emergency room (ER) visits provided 
on October 5, 2021, and November 15, 2021. 
 
You asked the Plan to waive the copayments for the ER visits. You say that you never went to the emergency 
room for anything related to COVID-19 on either date. 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 $120 
copayment for each emergency room visit.  
 
The medical record shows you had emergency room visits relating to COVID-19 on October 5, 2021, and 
November 15, 2021. You have been asked to pay a $120 copayment for each ER visit. ER visits 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 copayments for the emergency 
room (ER) visits provided on October 5, 2021, and November 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 17, 
2021. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 procedure code 70450 billed for date of service October 17, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurances and copayments for the injections, the 
medical supplies, and the diagnostic tests provided on October 21, 2021. 
 You asked the Plan to waive the coinsurances and copayments for the injections, the medical supplies, and the 
diagnostic tests. You say that you would like to appeal the claim and it all should have been billed as one. The 
Plan denied your request. The Plan says the proper cost share was applied to the services that were rendered. 
 
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 each Medicare-covered Part B drug. The total amount allowed for the first injection was $6.11 
with a coinsurance of $1.22 ($6.11 total amount allowed x 20% coinsurance). The total amount allowed for the 
second injection was $238.20 with a coinsurance of $47.64 ($238.20 total amount allowed x 20% coinsurance). 
The total coinsurance amount for both injections was $48.86. 
 
Your contract with the Plan also clearly says that you must pay a 20% coinsurance for each Medicare-covered 
medical supply. The total amount allowed for the medical supply was $222.20 with a coinsurance of $44.44 
($222.20 total amount allowed x 20% coinsurance). 
 
Your contract with the Plan also clearly says that you must pay a $50 copayment for Medicare-covered non-
radiological diagnostic services and pay a $175 copayment for Medicare-covered radiological diagnostic 
services, not including x-rays performed in a physician's office or at a free-standing facility. The total 
copayment for both the diagnostic test was $225 ($50 copayment + $175 copayment). 
 
You have been asked to pay a $48.86 coinsurance for the injections, a $44.44 coinsurance for the medical 
supplies, and a $225 copayment for the diagnostic tests. The injections falls within the Medicare Part B 
Prescription Drugs benefit category. The medical supplies and the diagnostic tests falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies 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 coinsurances and copayments for the injections, the medical supplies, and the diagnostic tests provided on 
October 21, 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 the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not have a need for intravenous 
medications, new tube feeding, ostomy care or daily complex wound care. You are walking household 
distances with a rolling walker with contact guard assistance and is contact guard assist for transfers. Provided 
records do not document a significant decline in your functional status compared to your recent baseline to 
necessitate daily inpatient skilled therapy services. You do not require the services on an inpatient basis, only in 
a skilled nursing facility setting. Services in the assisted living facility with home health care or in a long-term 
care facility on a part time basis appear appropriate in this case. 
 
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. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a flow cytometry, interpretation (88189) provided on 
November 16, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a flow cytometry, interpretation. You say that the patient's ordering physician is 
responsible for obtaining referral and or authorization. The Plan denied your request. The Plan says this 
provider is not a network provider with the Plan and the services were not referred by a network provider or 
rendered in an in-network facility. The Plan also says that they have also determined that these services are not 
urgent or emergent, nor were they 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 had network providers 
available who could have provided 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 a flow cytometry, interpretation (88189) provided 
on November 16, 2021, by an out-of-network (OON) provider.