Persius/hicric huggingface dataset:
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 feels that the enrollee is a good candidate for acute 
inpatient rehab and meets criteria for the service. 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 the complexity of the enrollee's nursing, medical and rehabilitation documented 
needs would not require an acute hospital inpatient stay with an 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - periapical each additional radiographic image 
(film) xs 3 provided on August 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you should not have to pay for the services 
received, the insurance should pay for the covered service. 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. Intraoral - periapical each 
additional radiographic image (film) is covered but is limited to one procedure code per calendar year. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested intraoral - periapical each additional radiographic image (film) xs 3 was 
exhausted on date of service August 18, 2022. The Plan covered the intraoral-periapical first radiographic 
image, you are responsible for the other three x-rays received. Therefore, we decided that the Plan does not 
have to pay for intraoral - periapical each additional radiographic image (film) xs 3 provided on August 18, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composite - one surface, posterior (D2391) and 
extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of 
mucoperiosteal flap if indicated (D7210) provided on August 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that you should not be responsible for this bill, the 
insurance should cover it. The Plan denied your request. The Plan says the dental services were received from 
an out-of-network provider and are not covered by your supplemental benefits. 
 
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. 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for resin-based composite - one surface, posterior (D2391) and extraction, erupted tooth requiring 
removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) 
provided on August 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2392) for tooth #13 provided on 
June 23, 2022. 
 
You asked the Plan to pay for the dental service. You say that it was medically necessary to get the dental 
procedure done. The Plan denied your request. The Plan says the documentation does not support the resin-
based composite per plan guidelines per insufficient clinical information with which to make a determination. 
 
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. The Plan covers the dental 
service when the services are medically necessary and reasonable.  
 
  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 dental service. Our reviewer says that the 
resin-based composite for tooth #13 is not medically necessary. Our physician reviewer found that in order to 
support the need for a restoration on a tooth, x-rays indicating that the tooth is present and has need of such a 
repair is necessary. Without any supporting documentation and x-rays to indicate the presence of the tooth and 
need for restoration the request cannot be supported. A claim form had indicated both a composite restoration 
and an amalgam restoration planned for the same tooth. The final claim should indicate the material used, as 
both could not be completed on the same tooth. Submitting pre-treatment x-rays would allow for a 
determination of need, and the final claim to indicate the material used. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental service have not been met. Therefore, we decided that the Plan does 
not have to pay for a resin-based composite (D2392) for tooth #13 provided on June 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair seat elevation system (E2300), 
expandable controller (E2377), harness (E2313), and electronic connection (E2311). 
 
You asked the Plan to pre-approve the power wheelchair accessories. You say that the items are medically 
necessary. The Plan denied your request. The Plan says the items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that if an item or service is not medically necessary it will 
not be 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 power wheelchair accessories. Our 
reviewer says that these items are not medically necessary. Our physician reviewer found the enrollee is not at 
high risk for skin breakdown, does not have major edema or contracture in lower extremities and has adequate 
upper extremity strength as demonstrated in her ability to transfer, to manage standard power switches. 
 
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 power wheelchair accessories have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a power wheelchair seat elevation system (E2300), expandable controller 
(E2377), harness (E2313), and electronic connection (E2311).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 19, 2022, billed with 
codes 0033U, 81479, 81291, 81306, 81355, 81335, 0031U, 0032U, 81231, 81232, 81241, 81225, 81227, and 
81230. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says panel testing should be billed using one 
CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 19, 2022, billed with codes 0033U, 81479, 81291, 81306, 81355, 81335, 0031U, 0032U, 81231, 81232, 
81241, 81225, 81227, and 81230.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
August 3, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service August 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for frames (V2020), and progressive lenses (V2781) 
provided on June 23, 2022. 
 You asked the Plan to pay more for frames (V2020), and progressive lenses (V2781). You say that your claim 
had been denied for some reason. The Plan denied your request. The Plan says they have paid the maximum 
amount covered by your plan for this service. 
 
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 reimburses up to $130 every year for non-Medicare covered prescription eyewear.  
 
We looked at the file and the Plan's rules. The Plan rules say they reimburse up to $130 every year for non-
Medicare covered prescription eyewear. The Plan rules also say you are responsible for any amount above the 
eyewear coverage limit. The record shows that this benefit was exhausted with this service. Based on this 
information, we decided that the Plan's rules for coverage of frames (V2020), and progressive lenses (V2781) 
have not been met. Therefore, we decided that the Plan does not have to pay more for frames (V2020), and 
progressive lenses (V2781) provided on June 23, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasound provided on August 3, 2022. 
 
You asked the Plan to waive the copayment for ultrasound. You say that you are disputing the share cost. 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 $100 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $100 copayment for ultrasound. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies 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 ultrasound provided on August 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sleep number bed (E1399), delivery (A9901), and sales 
tax (S999), provided on November 6, 2021. 
 
You asked the Plan to pay for the sleep number bed, delivery, and sales tax. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the item is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pay for the sleep number bed (E1399), delivery (A9901), and sales tax 
(S999), provided on November 6, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) provided 
from May 10, 2022, to May 28, 2022. 
 
You asked the Plan to waive the copayment for SNF. You say that you disagree with the copayment. 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 $0 
copayment per day for days 1-20 a $184 copayment per day for days 21-100 for skilled nursing facility (SNF).  
 
You have been asked to pay a $0 copayment per day for days 1-20 a $184 copayment per day for days 21-100 
for SNF. The total amount you are being asked to pay $3,128 ($184 x 17days = $3,128). However, you met 
your maximum out-of-pocket (MOOP) so you are only required to pay $2,447.62. 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 skilled nursing facility (SNF) provided from May 10, 2022, to May 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71250 billed for date of service June 27, 
2022. 
 
You asked the Plan to pay for procedure code 71250. You say that the enrollee had multiple exams on this date 
of service and the attached reports support the level of service. You say that the claim should be reconsidered 
for processing. The Plan denied your request. The Plan says there are no modifiers that are allowed with this 
code pair. 
 
  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 71250 
is a column II code to column I code 71260 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 71250 billed for date of service June 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 the documentation shows that you have resolving encephalopathy and require 
ongoing physical therapy, occupational therapy and speech therapy however, there is no documentation to 
show that you will tolerate 15 hours of therapy per week. 
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional physical therapy services. 
 
You asked the Plan to pre-approve 12 additional physical therapy services. You say that the enrollee's deficits 
impact their ability to get into her car, ambulate without a cane, ambulate long distances and negotiates curbs 
without a railing safely. You say that the enrollee is a great candidate to continue skilled therapy to increase 
their quality of life and return to prior level of function. The Plan denied your request. The Plan says additional 
physical therapy visits are not medically necessary, and the enrollee can transition to a home exercise program. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 the additional physical therapy services. 
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found the additional requested therapy 
generally is not accepted as specific and effective therapy for the enrollees condition beyond what was 
approved by the health plan. The requested services are not part of a maintenance program, and the specialized 
skill, knowledge and judgment of a qualified therapist is not required to establish, design or deliver a program 
to maintain the enrollee's current condition or to prevent or slow further deterioration. The enrollee can 
transition to an independent home exercise program. 
 
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 additional physical therapy services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 12 additional physical therapy services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on September 11, 2020, 
to September 13, 2020, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. The Plan denied your 
request. The Plan says there is lack of evidence to support the diagnoses. 
 
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 with diagnosis code N17.9, defined as unspecified acute kidney 
failure, and I50.32, defined as chronic diastolic (congestive) heart failure. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pay for the inpatient hospital services at the DRG originally billed. Our physician 
reviewer found that the enrollee presented to the emergency room reporting hypotension at home. However, 
her blood pressure was normal in the emergency room. Her creatinine (Cr) was elevated at 2.7, with potassium 
up to 5.6. Some medications were held, and she was given intravenous fluids. Her Cr dropped to 2.2 with 
potassium dropping to 5.0 within 22 hours, then down to 1.7. A baseline Cr was not documented in the 
provided notes. The notes describe the enrollee with congestive heart failure (CHF) but without imaging or 
other objective evidence of such to support the diagnosis for this admission. Also, the enrollee responded 
quickly to the fluids and medication changes without a clear baseline to describe a high enough rise in Cr 
during the admission to meet criteria for acute renal failure. Acute kidney injury would have been more 
appropriate in this case. Therefore, the diagnoses of N17.9 and I50.32 are each not supported in the 
documentation.   
 
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 hospital services provided on September 11, 2020, to September 13, 2020, at the Diagnosis 
Related Group (DRG) originally billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care, provided on March 17, 2022, 
through March 22, 2022. 
 
You asked the Plan to pay for the inpatient hospital care. You say that the service was medically necessary. The 
Plan denied your request. The Plan says they are unable to determine medical necessity of this service. 
 
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 the inpatient hospital care have been 
met. There were not medical records submitted in order to determine the medical necessity of the services provided. Therefore, we decided that the Plan does not have to pay for the inpatient hospital care, provided on 
March 17, 2022, through March 22, 2022.