Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 additional home health skilled nursing visits. 
You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan 
denied your request. The Plan says additional home health services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that additional home health care is not medically necessary. Our physician reviewer found that based on 
the medical records provided there is no documentation that additional skilled nursing services beyond what 
have already been approved by the health plan are required to effectively provide treatment, care, and/or 
services in order to improve the enrollee's condition, or to establish/perform a maintenance program to 
maintain the patient's condition and/or prevent deterioration. Provided records do not document any acute or 
unstable medical conditions or changes in medication or treatment which would necessitate any further skilled 
nursing visits beyond what have already been approved. The treatment plan for the left great toe wound from 
March 3, 2022, does not required the services of a skilled nurse. No medical notes from the enrollee's treating 
physician are provided documenting an order or need for additional skilled nursing services.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 2 additional home health skilled nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion office visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve a second opinion office visit. You say that the patient is seeking a second opinion for evaluation and treatment of her chronic right ankle pain from the surgeon who operated on her ankle 9 years ago. The Plan denied your request. The Plan says the provider you requested is not a network provider. The Plan also says that they have determined that a network provider can care for the enrollee's medical problem. The Plan also says that surgery is not suggested, and Medicare only covers second opinions for surgery.
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 second opinion office visit to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on January 11, 2021. 
 
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 procedure codes 63047 and 63048 are not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
The provider submitted a claim for procedure codes 63047 (Laminectomy, facetectomy and foraminotomy, 
single vertebral segment, lumbar), 63048 (Laminectomy, facetectomy and foraminotomy, single vertebral 
segment, each additional segment), and 22633 (Arthrodesis, combined posterior or posterolateral technique 
with posterior interbody technique). Codes 63047 and 63048 are column II codes with a modifier indicator of 1 
when billed with column I code 70496. The column II codes were not billed with an appropriate modifier to 
allow for separate payment. The records do not support the billing of the -XU modifier as a separate and 
distinct service. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on 
January 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on August 13, 2021. 
 
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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
We looked at the file and Medicare rules. The file does not contain documentation of an established 
relationship between the enrollee and the ordering provider. Without a record showing that this provider is 
treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the drug testing rendered on August 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye exam and eyeglasses provided on October 12, 2021.
You asked the Plan to pay for the eye exam and eyeglasses. The Plan denied your request. The Plan says there are no benefits available for services that are rendered from an out-of-network vision provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided by a provider with the Plan's vision vendor. We looked at the file and the Plan's rules. The file shows that the eye exam and eyeglasses were not provided by a provider with the Plan's vision vendor. Based on this information, we decided that the Plan's rules for coverage of the eye exam and eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for an eye exam and eyeglasses provided on October 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injection procedure for SI joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed (CPT code 27096).
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan denied your request. The Plan says your request is not medically necessary because you only obtained a 33% improvement in pain, which you described as a "little bit" of pain relief after your July 2021 sacroiliac injection. The Plan states thus, there is little evidence in the medical literature to suggest that this is an appropriate procedure for your pain and the magnetic resonance imaging (MRI) shows pressure on the L4 nerve in your back, and thus you have other problems which may be explaining your right sided pain.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 the service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case.
Our physician reviewer found there is no documentation of SI joint provocative testing being completed with positive findings on physical exam. The review has determined that the requested sacroiliac joint injections are not medically reasonable or 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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve injection procedure for SI joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed (CPT code 27096).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services you received on September 13, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider has opted 
out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
services you received on September 13, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the oral exam, cleaning, and dental x-rays provided on July 26, 2021. 
 
You asked the Plan to pay for the dental services. You say that you do not agree with this denial. The Plan 
denied your request. The Plan says that the provider has opted out of Medicare and cannot be paid by the Plan. 
 
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. The Plan has failed to provide evidence to support that the rendering provider 
had opted out of the Medicare program. Per our review of the opt-out database, this provider is not shown to 
have opted out. Without direct evidence to support that the provider has opted out, we find that the Plan's denial 
is not supported, and the services should be covered per the out-of-network benefits. Therefore, we decided that 
the Plan has to pay for the oral exam, cleaning, and dental x-rays provided on July 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from March 4, 2022, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from March 4, 2022, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary. 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from March 
4, 2022, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental health treatment 
beyond the date in question of March 4, 2022, forward. Our physician reviewer found you did not require 
inpatient mental health treatment beyond March 4, 2022, as you were not a danger to yourself or others and did 
not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking 
place beyond the date in question. It did not appear that the services for the dates in question were reasonably 
expected or medically necessary to improve your condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from March 4, 2022, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from March 4, 
2022, forward.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on August 9, 2021. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
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 date of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on August 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two amalgams (D2140 x2) provided on September 7, 
2021. 
 
You asked the Plan to pay for the amalgams. You say that you would like these services to be reconsidered 
because they should be covered. 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 two 
amalgams (D2140 x2) provided on September 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on November 1, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that according to your plan 
booklet, one oral exam is covered per year and this service was an exam. The Plan denied your request. The 
Plan says this service is not a covered expense under your dental plan. The Plan also says that you and your 
provider contacted the Plan multiple times prior to this date of service, and you were both educated on your 
plan benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 
problem focused limited oral evaluation (D0140) provided on November 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on October 21, 2021. 
 
You asked the Plan to pay for the prophylaxis. You say that you do not recognize this service and do not 
believe it is correct. The Plan denied your request. The Plan says your maximum benefit has been met for the 
2021 benefit year. 
 
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 Plan offers a $500 annual dental 
benefit maximum. The record shows that you met the annual maximum benefit on May 17, 2021 and your 
annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the 
prophylaxis (D1110) provided on October 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network services provided to the enrollee on August 
13, 2021. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The 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 out of network services provided to the enrollee on 
August 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and psychotherapy provided by an out-of-
network provider on December 16, 2021. 
 
  You asked the Plan to pay for the office visit and psychotherapy. You say that you never knew you needed a 
referral and would have gotten one if you knew. You say that neither the doctor or the Plan specified this, and 
you would like a chance to get a referral. The Plan denied your request. The Plan says this provider is not a 
network provider with the Plan and the services were not 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 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 office visit and psychotherapy provided by an 
out-of-network provider on December 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the small intestine x-ray rendered on July 26, 2021. 
 
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 procedure code 74250 is not separately payable. 
 
The rules say that if the modifier indicator is 0, the Column 2 code cannot be paid regardless of whether a 
modifier is used. 
 
We looked at the file and Medicare rules. The provider submitted a claim for procedure codes 74250 (x-ray 
small intestine) and 74246 (x-ray upper gastrointestinal tract). Code 74250 is a column II code with a modifier 
indicator of 0 when billed with column I code 74246. No separate payment is made for code G0480. Therefore, 
we decided that the Plan does not have to pay for the small intestine x-ray rendered on July 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services rendered on October 8, 2019. 
 
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 claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for these services was not filed until September 27, 2021. A valid Waiver of 
Liability (WOL) was not received until NOvember 19, 2021. This means that more than one calendar year from 
the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to 
pay for the critical care services rendered on October 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series (D0210), provided on November 8, 2021. 
 
You asked the Plan to pay for the complete series. You say that the service was medically necessary. The Plan 
denied your request. The Plan says you have exhausted the benefit for this service. 
 
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. Specifically, the records indicate you have already utilized the benefit 
for this service. Therefore, we decided that the Plan does not have to pay for the complete series (D0210), 
provided on November 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on 
October 25, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you believe this is not 
a routine oral exam and should be covered by your insurance. The Plan denied your request. The Plan says your 
dental plan covers two oral exams per calendar year, and the Plan previously benefitted oral exams on April 13, 
2021, and October 19, 2021. The Plan also says that benefits were not available for the additional oral exam 
done on October 25, 2021. 
 
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, oral exams are limited to two per 
calendar year. The record shows that you received oral exams on April 13, 2021, and October 19, 2021 and 
your oral exams benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the 
problem focused limited oral evaluation provided on October 25, 2021.