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

 
We decided that the Plan does not have to pay for medical services provided on August 15, 2022. 
 
You asked the Plan to pay for the medical services. You say that you do not believe that the patient was 
enrolled in hospice. The Plan denied your request. The Plan says the patient was enrolled in hospice on the 
dates of service in question. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. 
Specifically, the patient was enrolled from March 2, 2022, until October 27, 2022. Therefore, we decided that 
the Plan does not have to pay for medical services provided on August 15, 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 you need IRF care. The Plan denied your request. 
The Plan says an IRF admission is not medically necessary. 
 
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 your 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 you 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from November 1, 2020, to November 30, 2020. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. 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. 
Providers must report SNF services with the appropriate PDPM score. 
 
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 clinical documentation does 
not support that the enrollee received parenteral and/or IV feeding for a nutrition or hydration need during the 
period from November 1, 2020 to November 30, 2020. This was administered while not a resident. No oral or 
dental issues were identified. 
 
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) services provided to the enrollee from November 1, 2020, to 
November 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code C8908 billed for date of service July 18, 2022. 
 
You asked the Plan to pay for code C8908. You say that you have provided documentation to support payment. 
The Plan denied your request. The Plan says the coding of this claim does not meet requirements because you 
did not bill an appropriate diagnosis on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that imaging billed with code C8908 must be billed 
with an approved diagnosis in order to be paid. You billed this claim with diagnoses Z12.39 and Z91.89.  
Neither of these diagnoses is listed in the Medicare coverage article as approved diagnoses for code C8908. We 
looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage 
of code C8908 have not been met. Therefore, we decided that the Plan does not have to pay for code C8908 
billed for date of service July 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 14, 
2022. 
 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 July 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prefabricated resin crown (D2932) x 2 provided on July 12, 
2022. 
 
You asked the Plan to pay for dental services. You say that the provider stated they make crowns in-house to 
save insurance companies money, so you had the crowns done. You say you should not have to pay for the 
service. The Plan denied your request. The Plan says this service is not covered under your 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. Prefabricated resin crown 
(D2932) is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested Prefabricated resin 
crown (D2932) is not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pay for prefabricated resin crown (D2932) x 2 provided on July 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Cxbladder Monitor genetic test (0013M) billed for date of 
service May 10, 2022. 
 
You asked the Plan to pay for Cxbladder Monitor genetic testing. 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. Medicare rules say that the diagnostic laboratory test using NGS must 
have: 
- FDA approval or clearance as a companion in vitro diagnostic; and,  
- an FDA-approved or -cleared indication for use in that patients cancer; and,  
- results provided to the treating physician for management of the patient using a report template to specify 
treatment options.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Cxbladder Monitor genetic testing have not been met. Specifically, we found that the genetic 
testing at issue does not have FDA approval or clearance. Therefore, we decided that the Plan does not have to 
pay for a Cxbladder Monitor genetic test (0013M) billed for date of service May 10, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continued inpatient skilled nursing facility (SNF) care 
provided from April 22, 2022, through May 21, 2022. 
 You asked the Plan to pay for the SNF care. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the continued inpatient skilled nursing facility 
(SNF) care provided was 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 pay for the SNF care. Our reviewer says that the 
continued SNF care provided was not medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee did not require skilled nursing and/or skilled therapy services on a 
daily basis. The enrollee was walking household distances with a rolling walker with contact guard to 
minimum assistance and was contact guard assist for transfers. The therapy notes reported that she had reached 
her maximum rehabilitation potential as of April 21, 2022. Additionally, as a practical matter, the enrollee did 
not require these services on an inpatient basis only in a skilled nursing facility (SNF) setting. The services 
provided in the nursing facility appear custodial in this case from April 22, 2022 through May 21, 2022. 
 
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 SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the continued inpatient skilled nursing facility (SNF) care provided from April 22, 2022, 
through May 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mandibular partial denture (D5214) provided on August 2, 
2022. 
 
You asked the Plan to pay for dental services. You say that you were receiving care prior to the plan changes, 
so you want the Plan to pay for services. The Plan denied your request. The Plan says this service is not 
covered under your 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. Mandibular partial denture 
(D5214) is not covered under the Plans dental benefits. 
 
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 
mandibular partial denture (D5214) provided on August 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive periodontal evaluation - new/established 
patient provided on August 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told the bill would be covered under 
your plan. 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. This benefit includes the 
requested comprehensive periodontal evaluation - new/established patient but is limited to one procedure code 
every three calendar years. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. 
Comprehensive oral evaluation and periodontal evaluation have a shared frequency limit. The record shows 
you had periodontal evaluation on date of service May 31, 2022. Therefore, your benefit has been exhausted. 
Therefore, we decided that the Plan does not have to pay for comprehensive periodontal evaluation - 
new/established patient provided on August 8, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services received on July 
23, 2022. 
 
You asked the Plan to waive the copayment for the services. You say that the enrollee did not receive any care 
but still was billed. 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 a $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for the services. This item/service 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 copayment for emergency room services 
received on July 23, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on May 24, 2022. 
 
You asked the Plan to pay for the ambulance response. You say that this service should be covered because you 
were concerned for your health. The Plan denied your request. The Plan says this service is not covered when 
there is no transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.   
The ambulance company did not provide transport services on May 24, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on May 24, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service July 17, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service July 17, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service August 18, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service August 18, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided from June 13, 2022, to June 23, 
2022. 
 
You asked the Plan to pay for the medical services. You say that the patient was not on hospice on these dates 
of service. The Plan denied your request. The Plan says Original Medicare is responsible for this claim. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 The enrollee ended Medicare Hospice benefits on June 1, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for medical services provided 
from June 13, 2022, to June 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fabricated abutments (D6057), the crown (D6058), 
supported retainers (D6068), and the pontic (D6245) for tooth #1, #4, #5, and #6 provided by on July 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for the dental 
services. 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 the date of service of July 11, 2022. 
Prior to the date of service, the Plan paid $3,565.70 towards dental services for the year. On the date of service, 
the Plan paid $1,455. The total amount the Plan paid for towards the yearly dental services was $5,020.70 
which is greater than the yearly dental benefit amount. Therefore, we decided that the Plan does not have to pay 
for the fabricated abutments (D6057), the crown (D6058), supported retainers (D6068), and the pontic (D6245) 
for tooth #1, #4, #5, and #6 provided by on July 11, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from June 25, 2022, to July 24, 2022. 
 You asked the Plan to pay for SNF care. You say that this was medically necessary. The Plan denied your 
request. The Plan says there were no skilled nursing services needed or rendered during the period in question. 
 
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 there were no identifiable skilled nursing or skilled therapy services. The 
enrollee did not require skilled nursing or therapy services on a daily basis. The enrollee did not meet severity 
of illness or intensity of service criteria for 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 pay for skilled nursing facility (SNF) services provided to the enrollee from June 25, 2022, to July 24, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychotherapy visit provided on July 06, 2022. 
 
You asked the Plan to pay for a psychotherapy visit. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s).there was no preauthorization by a primary care provider (this is different than a 
referral) for an out-of-network (OON) provider or facility, and this was not an emergency. Therefore, we 
decided that the Plan does not have to pay for a psychotherapy visit provided on July 06, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for local anesthesia (D9215) and a consultation (D9310) 
provided on July 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for the dental 
services. The Plan denied your request. The Plan says the denial of payment for these services is correct, 
because the local anesthesia and consultation are not covered by the 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 local 
anesthesia (D9215) and a consultation (D9310) provided on July 7, 2022.