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

 
We decided that the Plan does not have to pre-approve Opdivo. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has metastatic non-small 
cell lung cancer. Opdivo is not Food and Drug Administration (FDA)-approved for the treatment of metastatic 
non-small cell lung cancer after progression on prior PD-L1 treatment. Use is not supported by the medical 
literature or major drug compendia for off-label use in this setting. The service is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Opdivo.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a triamcinolone injection (20610, J3301, 
G0463) rendered on July 15, 2021. 
 
You asked the Plan to waive the copayment for a triamcinolone injection. You say that you had a second 
opinion visit with this provider and during this visit this provider stated he agreed with the same treatment. You 
also say that instead of making another appointment, you asked this provider if he could do the treatment at this 
visit, and he said yes. The Plan denied your request. The Plan says you were 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 $300 copayment for outpatient hospital services 
for all other services other than certain wound care services for outpatient surgery, including services provided 
at hospital outpatient facilities and ambulatory surgical centers.  
 
You have been asked to pay a $300 copayment for a triamcinolone injection rendered in an outpatient hospital 
setting. Triamcinolone injections fall within the outpatient surgery, including services provided at hospital 
outpatient facilities and ambulatory surgical centers 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 a triamcinolone injection (20610, J3301, G0463) rendered on July 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crowns (D2740), resin-based filling (D2330) and surgical 
extractions (D7210) provided from April 8, 2021, to June 8, 2021. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to reimburse you for 
covered services (D2330, D2740, D7210) at the same rate that would be paid if they had been provided in-
network. The Plan denied your request. The Plan says out-of-network dental care is not covered by your dental 
benefit. 
 
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. Services not listed in the 
dental benefits chart of the contract are not covered. You are responsible for the full cost of services received 
from out-of-network providers. Though the Plan offers a dental benefit in excess of Medicare coverage, items or services received from out-of- network providers are not covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crowns (D2740), resin-based filling (D2330) and surgical extractions (D7210) provided from April 8, 
2021, to June 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planing services (D4341) provided on August 4, 2021, and August 23, 2021.
You asked the Plan to pay for periodontal scaling and root planing. You say that you were told that these services were covered by your Plan. The Plan denied your request. The Plan says these services are not covered by your dental benefit.
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 periodontal scaling and root planing services (D4341) provided on August 4, 2021, and August 23, 2021.
Your complaint about potential misinformation from a Plan representative is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care (99223) provided on October 3, 2021.
You asked the Plan to pay for the initial hospital care. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this claim was not billed with an appropriate primary diagnosis code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code 99223 is not supported in the record. Specifically, the primary diagnosis listed on the claim is R65.11. R65.1 has a code first note meaning that the underlying condition must be sequenced first. This is not an appropriate primary diagnosis code. Based on this information, we decided that Medicare rules for coverage of the initial hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the initial hospital care (99223) provided on October 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on March 18, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
 
 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. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the office visit provided on March 18, 2021, by an out-of-
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 sensor. 
 
You asked the Plan to pre-approve a Dexcom G6 sensor. You say that the requested device is medically 
necessary. 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 Plans may specify brands and manufacturers and 
limit the DME coverage to only those brands and manufacturers as long as the enrollee retains access to all 
medically necessary items.   
 
We looked at the file and Medicare rules. The Plan has indicated that this request was made for supplies from a 
pharmacy provider. Non-preferred brands are not covered from a pharmacy provider according to the enrollees 
contract. Based on this information, we decided that Medicare rules for coverage of a Dexcom G6 sensor have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 sensor.
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 fully meets the criteria for an IRF stay. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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 does not require treatment by multiple therapies and an intensive rehabilitation therapy 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 pre-approve a crown (D2751), and a prefabricated post and core in addition to a crown (D2954).
You asked the Plan to pre-approve a crown, and a prefabricated post and core in addition to a crown. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are not covered 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 pre-approve a crown (D2751), and a prefabricated post and core in addition to a crown (D2954).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the transthoracic echocardiography (TTE) 
you received on October 14, 2021. 
 
You asked the Plan to waive the copayment for the TTE. You say that you were not aware that there would be 
a separate copayment for this service. The Plan denied your request. The Plan says you were charged this 
copayment correctly. The Plan says that you were only charged one copayment for this date of service for the 
TTE.  You were not charged a separate copayment for the office visit itself. 
 
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 $50 
copayment for x-rays and ultrasounds.  
 
You have been asked to pay a $50 copayment for the TTE. A TTE is a type of ultrasound. 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 the transthoracic echocardiography (TTE) you received on October 
14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjunctive prediagnostic test (D0431), localized delivery 
of antimicrobial agents (D4381 x 12), gingival irrigation (D4921 x 4), drugs or medicaments (D9630 x 2), 
 
You asked the Plan to pay for the dental services. You say that you should not be responsible for these charges. 
The Plan denied your request. The Plan says the services you received are not listed as covered. 
 
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 services you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
adjunctive prediagnostic test (D0431), localized delivery of antimicrobial agents (D4381 x 12), gingival 
irrigation (D4921 x 4), drugs or medicaments (D9630 x 2),
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 6, 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 the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on July 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care rendered on August 16, 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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that physicians in the same group practice who are in the 
same specialty must bill and be paid as though they were a single physician. 
 
We looked at the file and Medicare rules. The file shows that a previous evaluation and management service 
was billed by a physician within the same group practice and paid for by the Plan for the date of service at 
issue. Therefore, we decided that the Plan does not have to pay for the initial hospital care rendered on August 
16, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the catheter insertion rendered on March 1, 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 32557 is 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 32557 (catheter insertion) and 71045 (chest x-ray). Code 
71045 is a column II code with a modifier indicator of 1 when billed with column I code 32557. The Plan paid 
code 71045 and denied code 32557 as a procedure-to-procedure edit. Therefore, we decided that the Plan does 
not have to pay for the catheter insertion rendered on March 1, 2021.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that you do not have complex rehabilitation, medical and nursing needs. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care.  You were admitted for a lower extremity infection and had a below the knee amputation. Your medical 
problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While you have 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 you will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our 
physician reviewer found that your condition does not meet Medicare criteria for IRF 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: 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 someone who can help you get around. The 
Plan denied your request. The Plan says the denial of authorization for IRF service is correct. 
 
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 your nursing, medical, and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation therapy. There is insufficient 
documentation to show that you need at least 3 hours for 5 days per week of therapy. There is not a reasonable 
expectation that you will be able to fully participate in - and benefit from - the interdisciplinary approach to 
rehabilitation 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from September 28, 2018, 
through October 2, 2018 with the reported secondary diagnosis code J96.01, acute respiratory failure with 
hypoxia. 
 
You asked the Plan to pay for inpatient services provided from September 28, 2018, through October 2, 2018 
with the reported secondary diagnosis code J96.01, acute respiratory failure with hypoxia. The Plan denied 
your request. The Plan says diagnosis code J96.01 for acute respiratory failure with hypoxia is not supported in 
medical records documentation and per review guidelines for symptoms and treatment. 
 
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 diagnosis code J96.01, acute respiratory failure with 
hypoxia. 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 inpatient services provided from 
September 28, 2018, through October 2, 2018 with the reported secondary diagnosis code J96.01, acute 
respiratory failure with hypoxia. Our reviewer says that the documentation does not support that the inpatient 
care is payable as billed. Our physician reviewer found that in this case, the enrollee was intubated for airway 
protection in the setting of altered mental status related to severe hyponatremia, seizure and Versed 
administration. Her pulse oximetry reading was in the range of 97%-to-99% prior to intubation. The enrollee 
was ventilated without difficulty. Once her neurological status stabilized, the enrollee was extubated without 
difficulty, with rapid transition from low-flow nasal oxygen to room air. The review has determined that the 
secondary diagnosis code J96.01, Acute respiratory failure with hypoxia was not supported by the medical 
records. 
 
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 services provided from September 28, 2018, through October 2, 2018 with the reported secondary 
diagnosis code J96.01, acute respiratory failure with hypoxia.