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

 
We decided that the Plan does not have to pay for retainer crowns (D6791) on tooth #29 and tooth #31 and the 
pontic (D6211) on tooth #30 provided by a provider on January 27, 2022. 
 
You asked the Plan to pay for the retainer crowns (D6791) on tooth #29 and tooth #31 and the pontic (D6211) 
on tooth #30. You say that the dental office gave you an incorrect out-of-pocket cost for the services. You say 
your provider should have known prior to the services what your cost would be. The Plan denied your request. 
The Plan says the out-of-pocket costs were applied correctly. 
 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 retainer crowns (D6791) on tooth 
#29 and tooth #31 and the pontic (D6211) on tooth #30 are among those covered under this benefit with 50% 
coinsurance. See chart below. 
 
Date of 
Service 
Service Maximum 
Approved 
Fee 
(MAF) 
Allowed 
Amount 
(AA) 
Coinsurance Coinsurance 
Liability 
Difference 
of MAF 
and AA 
Member 
Liability 
January 
27, 2022 
D6791 $960.00 $835.00 50% $417.50 $125.00 $542.50 
January 
27, 2022 
D6211 $960.00 $733.00 50% $366.50 $227.00 $593.50 
January 
27, 2022 
D6211 $965.00 $635.00 50% $317.50 $351.00 $647.50 
Total       $647.50 
 
Therefore, we decided that the Plan does not have to pay for retainer crowns (D6791) on tooth #29 and tooth 
#31 and the pontic (D6211) on tooth #30 provided by a provider on January 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH is the most appropriate level 
of care for this member. The Plan denied your request. The Plan says that your records do not show need 
continued treatments and care that can only be given in a hospital setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. The patient 
appears to be more stable and improving and should only require short-term additional acute care services that 
can safely be administered at the current facility until appropriate for a lower level of care. The patient does not 
require services at the LTACH that are not already available at the current facility. Our physician reviewer 
found that the enrollee's condition does not meet Medicare criteria for LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation (D0140) provided on February 25, 2022. 
 
You asked the Plan to pay for the limited oral evaluation. You say that the services should be covered as you 
disagree with the charges. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall under your supplemental dental coverage. 
 
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 limited 
oral evaluation (D0140) provided on February 25, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the professional component (PC) of the x-ray provided on November 2, 
2021. 
 
You asked the Plan to pay for the PC of the x-ray. You say that these were correctly billed on separate claims 
because the mobile provider purchased the services of the radiologist and is billing those in addition to the 
technical component (TC). The Plan denied your request. The Plan says that this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that payment must be made for the PC of radiology 
services in all settings. 
 
We looked at the file and Medicare rules. The Plan's rationale indicates that the TC was billed separately which 
is not allowed. However, no evidence of the billing of the TC was presented. The file only shows that the PC 
was billed and not paid, which is not supported by the rules. Based on this information, we decided that 
Medicare rules for coverage of the PC of the x-ray have been met. Therefore, we decided that the Plan has to 
pay for the professional component (PC) of the x-ray provided on November 2, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 19, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says genetic testing 
submitted with code 81455 are unlikely to impact therapeutic decision-making in the clinical management of 
the patient. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The genetic testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover 
this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
genetic testing provided on October 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services provided from June 22, 2021, to June 
27, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed DRG is not 
supported. 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 K92.1. 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 services. Our reviewer says that the use of diagnosis code K92.1 is 
not supported by the records provided. Our physician reviewer found that the enrollee is a 75-year-old male 
who presented with abdominal pain and anemia. The enrollee 
denied any evidence of bleeding. The emergency room report stated that the enrollee was denying dark tarry 
sticky stools. No rectal exam was performed as part of the emergency room evaluation or admission history 
and physical. There was no documentation confirming active melena upon admission. The enrollee underwent 
right colectomy on June 23, 2021. The postoperative diagnosis was: Right colon obstruction secondary to near 
obstructing mass, highly suspicious for cancer. 
The use of diagnosis code K92.1 was not supported by the records provided.  
 
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 the inpatient services provided from June 22, 2021, to June 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (62323). 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for coverage of 
the requested service have not been met. 
 
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 an epidural steroid injection. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee has not tried and failed 4 weeks of non-surgical or non-injection 
care, which includes appropriate oral medications and structured physical therapy to the extent tolerated. Any 
trials and responses were not documented. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection (62323).
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF care is not medically necessary and the enrollee's needs can be met at a lower 
level of care such as in a skilled nursing facility, at home with home health or at home with outpatient therapy. 
 
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 while the enrollee has a need for physical and/or occupational therapy, there is 
no documentation of a need for an intensive rehabilitation program such as 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ZIP Interspinous Fusion System. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee is being treated for spinal 
stenosis. He presented with severe spinal stenosis with neurogenic claudication. He is a poor surgical 
candidate. There is limited published, large-scale, long-term peer-reviewed literature that shows this request to 
be an effective and/or safe treatment for the noted pathology. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
request for ZIP Interspinous Fusion System is 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ZIP Interspinous Fusion System.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee is being treated for 
vertebrogenic low back pain, low back pain, intervertebral disc degeneration lumbosacral region, intervertebral 
disc degeneration lumbar region, spondylosis without myelopathy/radiculopathy lumbosacral region, and 
spondylosis without myelopathy/radiculopathy of the lumbar region. There is no detailed documentation 
regarding Modic changes demonstrated on the formal imaging study. There are multiple plausible pathologic 
sources of significant pain generation. The Intracept procedure is not reasonable or medically necessary at this 
time. 
 
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 an Intracept procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prostate screening testing rendered on April 4, 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 medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that prostate screening testing is covered when 
specific criteria are met. 
 
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 these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the submitted records do not contain 
documentation of results of prior prostate specific antigen (PSA) testing or the date the PSA was previously 
obtained. The criteria for coverage are not met and the testing was therefore 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 pay for the prostate screening testing rendered on April 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI), brain, provided on 
January 25, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the MRI. You say that the providers rely on the facility staff to obtain all 
necessary paperwork, including authorizations and referrals. The Plan denied your request. The Plan says prior 
authorization was not 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 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 magnetic resonance imaging (MRI), brain, provided on 
January 25, 2022 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 88341, 88342, 88360, and 
88381 provided on August 4, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 88341, 88342, 88360, and 88381 are not supported in the medical record. Specifically, 
these codes have Professional component/Technical component of 1. This identifier means that these codes 
generally have both a professional and technical component. Modifiers 26 and TC can be used with these 
codes. Review of the file shows that these services were billed with a place of service of 22 (On Campus-
Outpatient Hospital).  The professional interpretation was furnished in the same payment location from where the technical 
component was furnished. The professional interpretation of a diagnostic test must be separately billed with 
modifier 26 by the interpreting physician. This means that these services were not billed correctly. Based on 
this information, we decided that Medicare rules for coverage of the laboratory services have not been met. 
Therefore, we decided that the Plan does not have to pay for the laboratory services coded 88341, 88342, 
88360, and 88381 provided on August 4, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide visits from May 9, 2022, forward. 
 
You asked the Plan to pre-approve home health aide visits. You say that you need these services to go about 
your day. You say that you need someone to take you to your doctor appointments. You say that you need 
someone to help with your personal needs. You also say that you do not see well. The Plan denied your request. 
The Plan says the care can be met with less complex services. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 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 aide visits. Our reviewer 
says that the requested home health aide services are not medically necessary. Our physician reviewer found 
documentation does not show that home health aide services are medically necessary to treat an illness or 
injury. The reviewer found that your care needs appear to be chronic, daily and long-term. As such, the 
reviewer found that the requested home health aide services are not medically necessary or reasonable. 
 
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 aide visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health aide visits from May 9, 2022, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ankle-foot and heel orthotics provided on February 3, 2022. 
 You asked the Plan to pay for lower extremity orthotics. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of payment for these items is correct, because 
the records do not support the items billed on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of ankle-foot and heel orthotics provided 
on February 3, 2022. have been met. Specifically, neither the proof of delivery nor the shipping receipt 
submitted have been signed by the enrollee or a valid designee. Furthermore, the proof of delivery does not 
include specification of the items delivered to the enrollee to support that the codes billed on this claim were 
furnished to the enrollee. The plan requested supporting records but they were not submitted. Without this 
information, you have not furnished sufficient information to the Plan to justify payment of this claim as it has 
been billed. Therefore, we decided that the Plan does not have to pay for ankle-foot and heel orthotics provided 
on February 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99291) provided on September 21, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 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 99291 is "Critical care, evaluation and management of 
the critically ill or critically injured patient; first 30-74 minutes". 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the records do not show that 
30-74 minutes of critical care services were provided on the date of service in question. 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 the services (99291) provided on September 21, 2021.