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

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you are upset that your request for the SSBCI 
benefit was denied, because you did not know that it had to be updated. The Plan denied your request. The Plan 
says based on the information submitted, there is no documentation that you meet all three criteria for 
coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
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 SSBCI benefits. Our reviewer says that 
you do not meet the coverage criteria for SSBCI benefits. Our physician reviewer found while the provided 
medical records document that you have several complex chronic conditions and are at high risk for 
hospitalization, it is not clear that you require, and are receptive to, intensive care coordination. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do 
not have one of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan 
does not have to pre-approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite (D2331x2, D2392) provided from 
March 18, 2022, to November 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that the payment should have been issued to you and 
not the out-of-network provider. 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 3, 2022. Therefore, we decided that the Plan does not have to pay for the resin-based composite (D2331x2, D2392) 
provided from March 18, 2022, to November 3, 2022.
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 services are necessary for the enrollee to regain 
maximum function. The Plan denied your request. The Plan says 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 enrollee does not require treatment by multiple therapies. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an office visit (procedure code 99215) rendered on August 11, 2021. 
 
You asked the Plan to pay for the visit. You say that this should be paid for. The Plan denied your request. The 
Plan says that Current Procedural Terminology (CPT) code 99215 25 (1 unit) remains not supported. 
 
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 99215 is "Office or other outpatient visit for the evaluation and management of an established patient, 
which requires a medically appropriate history and/or examination and high level of medical decision making. 
When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter." 
 
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 visit. Our reviewer says that the services at issue in this 
case were supported by the medical records. Our reviewer found that the enrollee was seen by his cardiologist 
on 8/11/2021.  At that visit, the results of a cardiac monitoring device were assessed. Additionally, the enrollee 
reported TIA-like symptoms. As the cardiac monitor showed no atrial fibrillation, additional vascular 
evaluations were planned. The history and physical were medically appropriate. The medical decision making 
was highly complex. Therefore, the billing of CPT 99215 is supported. 
 
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 visit have been met. Therefore, we decided that the Plan has to pay for an 
office visit (procedure code 99215) rendered on August 11, 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from November 1, 2021, to November 2, 
2021. 
 You asked the Plan to pay for SNF care. You say that you disagree with the denial of payment for SNF care. 
The Plan denied your request. The Plan says that the SNF services were not authorized. 
 
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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee did not have documented skilled nursing and/or skilled therapy 
needs. Daily skilled services are not shown to have been required to establish a maintenance program or to 
prevent deterioration of the enrollees condition. 
 
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 pay for SNF care provided from November 1, 2021, to November 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (procedure code 99233) rendered on 
April 24, 2022. 
 
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 documents do not support the level of care. 
 
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 99233 is "Subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and high level of medical decision making. When using total time on the date of the 
encounter for code selection, 50 minutes must be met or exceeded." 
 
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 that the enrollee was evaluated for 
syncope and bacterial enteritis. She remained hemodynamically stable. On the date in question, the enrollee was improving and there was no documentation to support instability or a new problem. According to 
Medicare, CPT code 99233 can be used for subsequent hospital care, per day, for the evaluation and 
management of a patient with at least 2 of the 3 key components: a detailed interval history, a detailed 
examination, medical decision making of high complexity.  Usually, the patient is unstable or has developed a 
significant complication or a significant new problem and takes approximately 35 minutes at the bedside or the 
patients hospital floor or unit. In this case, the documentation doesnt support the CPT code 99233. 
 
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 subsequent hospital care (procedure code 99233) rendered on April 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental anesthesia for extractions. 
 
You asked the Plan to pre-approve dental anesthesia for extractions. You say that the enrollee has a complex 
medical history, which does not make her a candidate for receiving sedation in your office. The Plan denied 
your request. The Plan says for dental care per the enrollee's contract, covered services are limited to surgery of 
the jaw or related structures, setting fractures of the jaw or facial bones, extraction of teeth to prepare the jaw 
for radiation treatments of neoplastic cancer disease, or services that would be covered when provided 
by a physician. The requested facility fees for anesthesia services are not covered given the enrollee does not 
have a qualifying medical condition requiring outpatient hospital setting. 
 
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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve dental 
anesthesia for extractions.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee is unstable and will be unable to return 
home unless they get rehab at SNF. The Plan denied your request. The Plan says that the enrollee can remain in 
the hospital for additional testing for your weakness. 
 
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 the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found clinical documentation shows acute functional and clinical status change. Skilled 
therapy and nursing assessment would be medically necessary. Evaluating therapists recommend daily skilled 
therapy and services on an inpatient basis in a SNF is medically necessary. Plan denial was initially based on 
medical stability not medical necessity. SNF admission criteria is met. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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 Methotrexate. 
 
You asked the Plan to pre-approve Methotrexate. The Plan denied your request. The Plan says this drug is not 
covered under the enrollee's Part B plan. 
 
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 Methotrexate.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on February 19, 2022 to February 
22, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
submitted supporting documentation for reconsideration of DRG adjustment. The Plan denied your request. 
The Plan says that a post-service, post-payment clinical validation audit was performed to help ensure that the 
diagnosis codes on the claim supported clinically. 
 
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 872. 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 supported by the medical records. Our physician reviewer found that 
the appeal letter does support a diagnosis of sepsis, and that without further records to the contrary, the health 
plan has failed to support its denial. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient hospital services provided on February 19, 2022 to February 22, 2022, at the Diagnosis Related Group (DRG) 
originally billed.  
 
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 pay for an outpatient clinic visit provided out-of-area on September 
9, 2022. 
 
You asked the Plan to pay for the out-of-area outpatient clinic visit. You say that you were out of state and had 
kidney stones. You say that you were under the impression that this would be covered as emergency care. The 
Plan denied your request. The Plan says the records from this visit do not indicate that this was an emergency 
service. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
We looked at the file and Medicare rules. The records do not support that the condition which you were treated 
for was unforeseen. In addition, the records show that the treating physician discussed the option of going to 
the emergency room for further evaluation if your pain was severe, which you declined. The documentation provided does not support that services in dispute meet the definition of urgent or emergent. Based on this 
information, we decided that Medicare rules for coverage of the out-of-area outpatient clinic visit have not been 
met. Therefore, we decided that the Plan does not have to pay for an outpatient clinic visit provided out-of-area 
on September 9, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the electroencephalogram (EEG) provided on August 3, 2022. 
 
You asked the Plan to pay for the EEG. You say that this testing was clearly necessary. The Plan denied your 
request. The Plan says that this did not meet Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for the EEG. Our reviewer says that the services 
provided are considered medically reasonable and necessary in this case. Our physician reviewer found the 
enrollee was given an EEG after cardiac arrest to determine prognosis. This is a medically acceptable use of 
EEG and is considered 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 the EEG have been met. Therefore, we decided that the Plan has to pay for the 
electroencephalogram (EEG) provided on August 3, 2022.  
 
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: Favorable

 
We decided that the Plan has to pay for the trimming of dystrophic nails and treatment of hyperkeratotic lesions 
provided on August 19, 2022. 
 
You asked the Plan to pay for the foot care services. You say that this should be covered. The Plan denied your 
request. The Plan says that this service is not covered by Medicare. 
 
BCBS must follow Medicare rules. The rules say that routine foot care is not a covered Medicare benefit unless 
you have diabetic foot disease or some other condition that makes professional care of your feet medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Part C Plan was correct in denying the request to pay for the foot care services. Our reviewer 
says that the criteria for Medicare coverage of routine foot care have been met. Our physician reviewer found 
the enrollee was seen by a podiatrist for thick painful toenails and callous. The physical examination reveals 
non-palpable pedal pulses bilaterally. A diagnosis of atherosclerosis was made by the podiatrist. Medicare 
guidelines advise that Medicare payment may be made for routine foot care when the patient has a systemic 
disease, such as a metabolic, neurologic, or peripheral vascular disease, of sufficient severity that performance 
of such services by a nonprofessional person would put the patient at risk (for example, a systemic condition 
that has resulted in severe circulatory embarrassment or areas of desensitization in the patients legs or feet).   
 
In this particular case, it appears that this enrollee's nonpalpable pulses and diagnosis of atherosclerosis meet 
the Medicare criteria for coverage of routine foot 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 foot care services have been met. Therefore, we decided that the Plan has to 
pay for the trimming of dystrophic nails and treatment of hyperkeratotic lesions provided on August 19, 2022.  
 
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.