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

 
We decided that the Plan does not have to pay for the services provided on July 31, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is not 
enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the services provided on July 31, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 testing (81479) provided on July 23, 2021.
You asked the Plan to pay for Guardant360 testing. You say that this was billed correctly. The Plan denied your
request. The Plan says this was not billed with the correct place of service.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place
where the sample was taken is reported as the Place of Service (POS).
We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent
laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we
decided that Medicare rules for coverage of Guardant360 testing have not been met. Therefore, we decided that
the Plan does not have to pay for Guardant360 testing (81479) provided on July 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) 
provided November 10, 2021. 
 
You asked the Plan to pay for the periapical x-ray. You say that the coverage documents do not specify which 
types of x-rays are covered and which are not. The Plan denied your request. The Plan says this service is not 
covered under your benefit. 
 
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 
intraoral - periapical first radiographic image (D0220) provided November 10, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown (D2750) for tooth #9. 
 
You asked the Plan to pre-approve the crown. You say that you would like the crown for tooth #9 to be 
approved. The Plan denied your request. The Plan says that it is not medically necessary to replace the cap on 
your tooth. 
 
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 did not provide a copy of the applicable digital quality x-rays for this 
case. We asked for this document, but it was not provided to us. Without this information we cannot determine 
that the Plan's coverage rules support the denial of payment in this case. The x-rays that were provided are not 
considered to be digital quality. Consequently, the Plan has not substantiated their denial of payment in this 
case. Therefore, we decided that the Plan has to pre-approve a crown (D2750) for tooth #9.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a partial denture repair (D5611) provided by a participating 
provider on November 4, 2021. 
 
You asked the Plan to pay for a partial denture repair. You say that your denture broke in the same spot that 
was previously fixed. You say that you should not have to pay for this. The Plan denied your request. The Plan 
says the benefit limit for this 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 Plan's coverage rules apply in this case. The Plan covers one partial 
denture repair per Plan year.  We looked at the file and Medicare rules. Evidence was provided to show that D5611 was provided on September 16, 2021. Based on this information, we decided that the Plan's rules for coverage of a partial 
denture repair have already been met. Therefore, we decided that the Plan does not have to pay for a partial 
denture repair (D5611) provided by a participating provider on November 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency services provided on August 27, 2021. 
 
You asked the Plan to pay for the services provided. You say that the medical records support the claim as 
submitted. The Plan denied your request. The Plan says no separate payment is made. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  In this case, the CPT Code Manual definition of code 99053 is service(s) provided between 10:00 PM and 8:00 
AM at 24-hour facility, in addition to basic service. We find that CPT code 99053 is a bundled code. When 
these services are covered, payment for them is subsumed by the payment for the services to which they are 
incident. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, 
we decided that the Plan does not have to pay for the emergency services provided on August 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 27, 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 81295 and 81298 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 81295 (MSH2 full gene sequencing), 81298 (MSH6 full 
gene sequencing), and 81432 (hereditary breast cancer panel). Codes 81295 and 81298 are column II codes 
with a modifier indicator of 1 when billed with column I code 81432. The column II codes were not billed with 
an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to 
pay for the laboratory services rendered on July 27, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you need to have more rehabilitation in order to 
return home safely. You say that it is unsafe to be discharged. You say that you do not have to be in an acute 
setting. The Plan denied your request. The Plan says SNF services are not reasonable and necessary at this 
time. The Plan says that the enrollee is not medically stable. The Plan says that the enrollee's needs may be met 
in the current hospital setting.  
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there is no documentation that the 
patient requires skilled nursing services. The enrollee does require skilled therapy services, but they are not 
required on a daily basis. There is no documentation that the enrollee requires or could tolerate the services on 
a daily inpatient basis only in a skilled nursing facility setting. Records are not clear that the enrollee is stable 
for daily therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on May 28, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says no separate 
payment should be made. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 In this case, the CPT Code Manual definition of code 99100 is anesthesia for patient of extreme age, younger 
than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure). We find 
that CPT code 99100 is a bundled code. When these services are covered, payment for them is subsumed by the 
payment for the services to which they are incident. Based on this information, we decided that Medicare rules 
for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to 
pay for the anesthesia services provided on May 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99140) provided on October 7, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee 
Schedule indicates that payment for covered services are always bundled into payment for other services not 
specified.  
 
We looked at the file and Medicare rules. Code 99140 is assigned a status indicator of B under the Physician 
Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into payment for 
other services. No separate payment can be made for this service.  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 (99140) provided on October 7, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the medical nutrition therapy (MNT) services provided via telehealth 
on August 9, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON telehealth MNT services. You say that you believe that this should be 
paid due to medical necessity. The Plan denied your request. The Plan says that the Medicare rules say that 
telehealth services can only be provided in-network. The contract clearly states that OON telehealth services 
are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that health plans may choose to offer additional 
telehealth services that are treated as basic Medicare benefits, and that these must be provided by network 
providers only. However, for the COVID-19 public health emergency (PHE), the limitations on the types of 
providers able to offer telehealth services have been waived. 
 
In this case, though the Plan can only cover "additional telehealth services" from network providers, during the 
PHE, this type of service is not an additional telehealth benefit offered by the Plan. All providers who can bill 
Medicare can be paid for telehealth services, and as this Plan covers Medicare services from OON providers, 
these services cannot be denied due to the limitations imposed for "additional telehealth benefits". Therefore, 
we decided that the Plan has to pay for the medical nutrition therapy (MNT) services provided via telehealth on 
August 9, 2021, by an out-of-network (OON) provider.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a tooth extraction (D7210) provided by a participating 
provider on November 1, 2021. 
 
You asked the Plan to pay for a tooth extraction. You say that you were told that your extractions would be 
covered. The Plan denied your request. The Plan says the surgical extractions that were provided 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 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 a tooth 
extraction (D7210) provided by a participating provider on November 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on October 5, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for imaging services provided to the enrollee on October 5, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee is in need of rehabilitation to return 
home. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The 
enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on 
an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from June 17, 2021, to 
July 12, 2021. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's 
condition no longer required daily skilled services at an inpatient SNF level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from June 17, 2021, to July 12, 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 the consistency of finding in favor of IRF referrals 
suggests that stroke survivors who qualify for IRF services should receive this care in preferences to skilled 
nursing facility-based care. The Plan denied your request. The Plan says needs can be met at a lower level of 
care. 
 
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 there are no acute rehabilitation or nursing needs identified in the record. On a 
review of the available records, you have debility from chronic obstructive pulmonary disease exacerbation and 
do not meet the coverage criteria for this admission. You are medically stable and does not need physician 
supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations 
of chronic medical conditions. You do not need intensive therapies, consisting of at least 3 hours of therapy per 
day at least 5 days per week with multidisciplinary approach to daily therapy in an IRF. You do not have the 
endurance to undergo IRF level of therapies. You need routine therapy, but not an inpatient admission. IRF 
admission is not medically necessary based on lack of medical complexity and lack of acute rehab nursing 
needs. Your rehab needs can be met safely continued at a lower intensity and alternate setting such as in an 
SNF. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasound services provided to the enrollee on November 5, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for ultrasound services provided to the enrollee on November 5, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (82542, 84228, G0483) provided on 
September 24, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you were not aware of the requirement of 
obtaining a prior authorization, specifically for this member's plan type at the time of rendering services. The 
Plan denied your request. The Plan says the request is from an out-of-network provider and both the servicing 
provider, and the referring provider are out-of-network. The Plan also says that it has been pointed out to this 
provider on multiple occasions that preauthorization is required for the requested testing, and there is no 
documentation from the patient's doctor as to why 22 drug classes are needed to manage this patient's care 
 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 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 laboratory services (82542, 84228, G0483) 
provided on September 24, 2021, by an out-of-network (OON) provider.