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 the requested IRF care is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says medical necessity rules for IRF care have not been met. 
 
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.  While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening (71271). 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that you are requesting a reconsideration 
of the Plan's denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
coverage of this service. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
  
We reviewed the case file and Medicare rules. Based on this information, we find that the enrollee does not 
meet Medicare criteria for coverage of this service. Specifically, the rules say that Medicare covers one annual 
LDCT scan for lung cancer screening for enrollees who are between 55 and 77 years of age. Therefore, we 
decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening (71271).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on April 4, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 office visit at issue in this appeal. The Plan did not pre-approve the 
office visit at issue. We found no exception that would require the Plan to pay for the office visit. Therefore, we 
decided that the Plan does not have to pay for office visit provided on April 4, 2022, by an out-of-network 
(OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images 
(D0210) provided March 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that your new provider required a full-mouth series 
of x-rays. 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service November 11, 2019. 
Therefore, we decided that the Plan does not have to pay for the intraoral - complete series of radiographic 
images (D0210) provided March 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided from April 6, 2022, to April 25, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you spoke with a Plan rep and was advised that all of 
your doctors and medicines would be covered. You also say that you are now receiving bills from your doctors 
and other medical expenses that have gone unpaid. The Plan denied your request. The Plan says this provider is 
not a network provider with the Plan and the services were not referred by a network provider or rendered in an 
in-network facility. The Plan also says that they have also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 an office visit provided from April 6, 2022, to 
April 25, 2022, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at-home COVID-19 test kit purchased on January 15, 
2022. 
 
You asked the Plan to pay for the at-home COVID-19 test kit. You say that you would like to be reimbursed 
for this test kit. The Plan denied your request. The Plan says COVID-19 home testing kits are not covered by 
your plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the at-home 
COVID-19 test kit is an OTC item. The Plan does not offer a supplemental benefit covering this service as this 
is not currently required by Medicare. However, for future purchases, these can be obtained with participating 
providers and covered by Original Medicare when using your Medicare card rather than your Plan card. 
Neither Medicare nor your Plan currently offers reimbursement of purchased COVID tests. Therefore, we 
decided that the Plan does not have to pay for the at-home COVID-19 test kit purchased on January 15, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the scanning computerized ophthalmic diagnostic imaging 
(92133) provided on November 2, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician service. You say that the service was medically necessary. The 
Plan denied your request. The Plan says prior authorization was not obtained before the service was rendered to 
the enrollee. The Plan says that the enrollee's primary care physician did not refer them for the service. The 
Plan also says there is no network deficiency for the service. 
 
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 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 the scanning computerized ophthalmic diagnostic 
imaging (92133) provided on November 2, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve orbitotomy without bone flap. 
 
You asked the Plan to pre-approve the orbitotomy. The Plan denied your request. The Plan says this is 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 the orbitotomy. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the photographs in the case file do not show the medical condition at issue in this case. 
Orbitotomy is an incision into the orbit, which is generally used for the removal of orbital tumors and for 
orbital decompression. The available documentation in the case file does not support that an orbitotomy 
without bone flap is medically reasonable and necessary for the enrollee in this case. 
 
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 orbitotomy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve orbitotomy without bone flap.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic x-ray (D0330) provided on April 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on the same date of service April 18, 2022. 
Therefore, we decided that the Plan does not have to pay for a panoramic x-ray (D0330) provided on April 18, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77003 billed for date of service July 14, 
2021. 
 You asked the Plan to pay for procedure code 77003. You say that these services are supported as billed. The 
Plan denied your request. The Plan says payment for code 77003 is bundled into payment for code 64490. 
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 77003 
is a column II code to column I code 64490. 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 procedure code 77003 billed for date of service July 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the pathology examination of tissue using a 
microscope provided from February 23, 2022, to March 16, 2022. 
 
You asked the Plan to waive the copayment for the tissue exam. You say that you should not have to pay for 
these two tests because the provider messed them up. The Plan denied your request. The Plan says you have 
been 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 $5 
copayment for diagnostic lab services.  
 
You have been asked to pay a $10 copayment for two tissue exams ($5 per test x 2 tests = $10). Laboratory 
testing 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 the pathology examination of tissue using a microscope 
provided from February 23, 2022, to March 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management (99239) billed for date 
of service October 7, 2021. 
 
You asked the Plan to pay for hospital discharge day management. You say that this service was reported 
appropriately. The Plan denied your request. The Plan says the records provided do not support this service 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. 
 
In this case, the CPT Code Manual definition of code 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the time spent providing this 
service is not noted in the medical record. Without this information, a time-based code such as 99239 cannot be 
verified. Based on this information, we decided that Medicare rules for coverage of hospital discharge day 
management have not been met. Therefore, we decided that the Plan does not have to pay for hospital 
discharge day management (99239) billed for date of service October 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services coded 99152 provided on 
March 3, 2022. 
 
You asked the Plan to pay for the moderate sedation services as billed. You say that you would like this claim 
reprocessed based on the medical records. The Plan denied your request. The Plan says the submitted medical 
records do not support the CPT code 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. 
 
In this case, the CPT Code Manual definition of code 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the medical record provided 
does not indicate the presence of an independent trained observer as the description of the code requires. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services as 
billed have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation 
services coded 99152 provided on March 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and 
adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and 
malignant lesions, not to include cytology or biopsy procedures (D0431) provided December 27, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that these services would 
not be covered. The Plan denied your request. The Plan says your benefit for the limited oral exam has already 
been exhausted and the adjunctive pre-diagnostic tests are not covered under your 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, certain limitations apply. The record shows your benefit for the limited oral exam was exhausted on date of service July 8, 2021. Additionally, the 
adjunctive pre-diagnostic tests are not covered under your benefits. Therefore, we decided that the Plan does 
not have to pay for the limited oral evaluation - problem focused (D0140) and adjunctive pre-diagnostic test 
that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include 
cytology or biopsy procedures (D0431) provided December 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on April 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that the provider told you they accept your insurance 
plan. 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 dental services provided on April 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 1, 2022, billed with 
codes 81226 and 81225. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says the claim has not been billed as 
required by Medicare coding regulations. 
 
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 
March 1, 2022, billed with codes 81226 and 81225.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the radiologic examination (X-ray) of the 
knee provided on April 13, 2022. 
 
You asked the Plan to reduce the copayment for the X-ray. You say that you called the facility before you went 
and were told it was a free-standing facility therefore, a $25 copay. The Plan denied your request. The Plan 
says you have been 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 $90 
copayment for basic radiological services at an outpatient hospital.  
 
You have been asked to pay the allowed amount of $85.54, which is less than the $90 copayment for an X-ray. 
The X-ray 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 reduce the copayment for the radiologic examination (X-ray) of the knee provided on 
April 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Trinity Elite allograft (20930) for spinal surgery. 
 
You asked the Plan to pre-approve a Trinity Elite allograft. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for coverage 
have not been met because the requested services are experimental/investigational. 
 
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 a Trinity Elite allograft. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows 
a Trinity Elite allograft to be an effective and/or safe treatment for the enrollee's pathology. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Trinity Elite allograft have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Trinity Elite allograft (20930) for spinal surgery.