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

 
We decided that the Plan does not have to pay for continuation of SNF services provided from October 1, 2021, 
through October 26, 2021. 
 
You asked the Plan to pay for continuation of SNF services. The Plan denied your request. The Plan says 
clinically the member's condition no longer required daily skilled services at an inpatient skilled nursing facility 
(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 continuation of SNF services provided from 
October 1, 2021, through October 26, 2021. Our reviewer says that daily skilled services are not medically 
necessary. Our physician reviewer found that based on the documentation provided, the enrollee did not qualify 
for SNF coverage. The enrollee did not have documented skilled nursing needs. The enrollee did not have 
documented skilled therapy needs. Daily skilled services were not required to establish a maintenance program 
or to prevent deterioration of the enrollees condition. The enrollees care needs, custodial and intermittent, 
could, as a practical matter, be provided at a lower level of care (ex. long term 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 continuation of SNF services provided from October 1, 2021, through  
October 26, 2021 have not been met. Therefore, we decided that the Plan does not have to pay for continuation 
of SNF services provided from October 1, 2021, through October 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on October 14, 2021. 
 
You asked the Plan to pay for the testing services. You say that a more complex drug screening was provided. 
The Plan denied your request. The Plan says the billed code cannot be verified. 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage have not been met. Specifically, this claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does 
not have to pay for the lab testing services provided on October 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implants (D6010 x 6), abutment supported porcelain 
crowns (D6058 x 6), abutment supported porcelain fused to metal crown (D6060 x 6), and a sinus 
augmentation (D7951). 
 
You asked the Plan to pre-approve the dental services. You say that the requested services are medically 
necessary. The Plan denied your request. The Plan says implants and associated services are not covered. The 
Plan also says that sinus augmentation is not covered either. 
 
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 implants and related 
services are not among those covered under this benefit. Sinus augmentation is not among those covered under 
this benefit either. Therefore, we decided that the Plan does not have to pre-approve implants (D6010 x 6), abutment supported porcelain crowns (D6058 x 6), abutment supported porcelain fused to metal crown (D6060 x 6), and a sinus augmentation (D7951).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two applications of desensitizing resin (D9911 x2). 
 
You asked the Plan to pre-approve the applications of desensitizing resin. The Plan denied your request. The 
Plan says this service is not covered under your benefit plan. 
 
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 pre-approve two 
applications of desensitizing resin (D9911 x2).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 10, 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 87651, 87798, 87491, 87529, 87481, 87661, 87496, 87653, 87556, 
87532, and 87640 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 87801, 87653, 97086, 87651, 87798, 87491, 87529, 87481, 87661, 87496, 87653, 87556, 87532, and 87640. Codes 87651, 87798, 87491, 87529, 87481, 87661, 87496, 87653, 87556, 87532, and 87640 are column II codes with a modifier indicator of 1 when billed with column I code 87801. 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 August 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services provided on January 14, 2021, billed 
with code 99291-25-27. 
 
You asked the Plan to pay for the critical care services as billed. You say that this should be paid as billed. The 
Plan denied your request. The Plan says only one of the two critical care visits is appropriately documented. As 
such, payment has been approved for code 99291-25 only. 
 
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. The rules say that facilities should only bill code 99291 if at least 30 minutes 
of time is spent with the patient. 
 
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 critical care services provided on 
January 14, 2021, billed with code 99291-25-27 have been met. Specifically, the progress note from the second 
emergency room visit does not clearly document that at least 30 minutes of face-to-face time was spent with 
the patient. Without this documentation, it is not appropriate to bill this second visit using the critical care code. 
Therefore, we decided that the Plan does not have to pay for the critical care services provided on January 14, 
2021, billed with code 99291-25-27.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services (01270, 99100 and 99140) and 
echocardiography (93355) provided on August 6, 2021 
 
You asked the Plan to pay for the anesthesia services and echocardiography. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the records 
submitted do not support the services billed. 
 
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. The rules also say that providers must report services correctly. 
 
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 anesthesia services (01270, 99100 
and 99140) and echocardiography (93355) provided on August 6, 2021 have been met. Specifically, the 
medical records submitted are not legible. There is insufficient information to determine if CPT code 01270 is 
supported in addition to the approved anesthesia code, 01926. Additionally, CPT codes 99100 and 99140 have 
a status indicator of B. This means that the payment for CPT codes 99100 and 99140 is always bundled into 
another service or procedure. Finally, CPT code 93355 is a column II code to column I code 01926. A modifier 
is not allowed to bypass this edit. Therefore, we decided that the Plan does not have to pay for the anesthesia 
services (01270, 99100 and 99140) and echocardiography (93355) provided on August 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller and related controls (E2311, 
E2377, E2313) and power seat elevation feature (E2300). 
 
You asked the Plan to pre-approve an expandable controller. You say that this item is medically reasonable for 
the enrollee's condition and proper operating of the power wheelchair. The Plan denied your request. The Plan 
says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a power seat elevation feature (E2300) is non-covered 
because it is not primarily medical in nature. The rules say that an expandable controller is subject to the 
criteria listed 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 an expandable controller. Our reviewer 
says that the requested device is not medically reasonable and necessary. Our physician reviewer found based 
on the medical records provided there is no documentation that the expandable controller and related controls 
meet Medicare criteria for medically necessary. Provided records document that the enrollee has "normal" 
upper extremity strength (physical examinations on November 22, 2021, and December 29, 2021) and is 
independent with grooming and hygiene thus indicating she has adequate upper extremity strength and function 
to operate the wheelchairs power options with their own switches. In addition, the power seat elevation feature 
is statutorily non-covered because it is not primarily medical in nature. 
 
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 expandable controller have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an expandable controller and related controls (E2311, E2377, E2313) and power 
seat elevation feature (E2300).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia for patient of extreme age (99100) provided 
on March 1, 2021. 
 
You asked the Plan to pay for the anesthesia for patient of extreme age. You say that you would like this claim 
reprocessed based on the medical documentation. The Plan denied your request. The Plan says payment for this 
code is always bundled into payment for other services not specified. 
 
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 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 looked at the file and Medicare rules. In this case, code 99100 has a Status Code of "B" under the 
Physician Fee Schedule. This Status Code indicates that payment for covered services are always bundled into 
payment for other services not specified.  Based on this information, we decided that Medicare rules for 
coverage of the anesthesia for patient of extreme age have not been met. Therefore, we decided that the Plan 
does not have to pay for the anesthesia for patient of extreme age (99100) provided on March 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye exam provided on November 
3, 2021. 
 
You asked the Plan to waive the copayment for a medical eye exam. You say that you have never received a 
copayment claim before. You are also asking that the case be dismissed. 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 $35 
copayment for in-network eye exam.  
 
You have been asked to pay a $35 copayment for a medical eye exam. A medical eye exam falls within the 
Vision Care benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for a medical eye exam 
provided on November 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on April 14, 2021, described 
by codes 95909, 95886, and 95999. 
 
You asked the Plan to pay for the services as billed. You say that this is billed correctly. The Plan denied your 
request. The Plan says these codes are 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 95909 is Nerve conduction studies; 5-6 studies. Code 
95886 is defined as Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, 
innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary 
procedure). Code 95999 is defined as Unlisted neurological or neuromuscular diagnostic procedure. 
 
We asked our coder 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 as billed. Our reviewer says that the 
documentation does not support the use of these codes. Our reviewer found pedicle screw stimulation was 
performed, and this procedure would not be reported with nerve conduction studies, as they are not the same 
procedure. Nerve conduction studies (95909) are used to determine if nerve damage is present on motor and 
sensory neurons. A stimulating and recording electrode are placed over a nerve (e.g. the Ulner or Median 
nerve). The time it takes for the impulse to reach the recording electrode is termed the latency. Latencies are on 
the order of milliseconds. The conduction velocity is calculated by dividing the distance between the electrodes 
by the latency, which equals the conduction velocity. In this case, nerve conduction studies were not 
performed.  
 
The procedure 95886 is done with nerve conduction studies, documentation does not support nerve conduction 
studies, therefore this procedure is not covered. Also, the provider is reporting train of four with an unlisted 
procedure code (95999). Train of four monitoring is considered integral to intraoperative monitoring and 
therefore not separately reported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the medical services provided on April 14, 2021, described by codes 95909, 95886, 
and 95999.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism with power recliner chair. 
 
You asked the Plan to pre-approve a seat lift mechanism with power recliner chair. You say that this is 
medically necessary. The Plan denied your request. The Plan says a power recliner is not medical in nature and 
not covered. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section 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 pre-approve a seat lift mechanism with power 
recliner chair. Our reviewer says that the requested seat lift mechanism is not medically reasonable and 
necessary. Our physician reviewer found that in this case, the documentation does not indicate that the member 
has severe neuromuscular disease or that they are incapable of standing up from a regular armchair or any chair 
in their home. In this case, the documentation doesn't support that the member has severe arthritis of the hip or 
knee or severe neuromuscular disease. She is non-ambulatory in the home. The requested seat lift mechanism is 
not medically reasonable and necessary. The power recliner will be denied as well as not being medical in 
nature. 
 
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 seat lift mechanism with power recliner chair have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a seat lift mechanism with power recliner chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the autologous blood or component, collection and 
processing (86891), special pump services (99190 and 99191) and washed red blood cells (P9022) provided on 
September 1, 2021. 
You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says services are included in payment to the 
facility. 
 
The Plan must follow Medicare rules. Medicare rules say that all items and non-physician services furnished to 
inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. 
 
We looked at the file and Medicare rules. In this case, the record indicates that the member was registered 
inpatient on the billed date of service. Payment for these services is included in the payment to the facility and 
is the responsibility of the facility to any vendor. Based on this information, we decided that Medicare rules for 
coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for the autologous blood or component, collection and processing (86891), special pump services (99190 and 
99191) and washed red blood cells (P9022) provided on September 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two custom fabricated abutments (D6057 x2) and two 
abutment supported porcelain fused to metal crowns (D6059 x2). 
 
You asked the Plan to pre-approve the custom fabricated abutments and abutment supported porcelain fused to 
metal crowns. You say that these services were already provided and you paid the dentist for them. You also 
say that you would like to be refunded for these services. The Plan denied your request. The Plan says these 
services are not covered under your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve two 
custom fabricated abutments (D6057 x2) and two abutment supported porcelain fused to metal crowns (D6059 
x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endosteal implants (D6010 x 9). 
 
You asked the Plan to pre-approve dental services. You say that you have several painful teeth. You say that 
want these services to be approved. You also say that you want the problems in your mouth to be heal. The 
Plan denied your request. The Plan says dental implants and all associated services are excluded from 
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 endosteal implants are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
endosteal implants (D6010 x 9).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement graft (D7953) and gingival irrigation 
(D4266) for tooth # 10. 
 
You asked the Plan to pre-approve the dental services. You say that you have been depressed. You say that you 
do not want to go back to that state. You also say that your teeth are a mess. The Plan denied your request. The 
Plan says bone replacement graft is not listed as a covered service. The Plan says that gingival irrigation is not 
listed as a covered service either. 
 
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 bone replacement graft and gingival irrigation are not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pre-approve bone replacement graft (D7953) and gingival irrigation (D4266) for tooth # 10.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram provided on June 21, 2021. 
 
You asked the Plan to pay for the testing services. You say that the medical records support the claim. The Plan 
denied your request. The Plan says an appropriate modifier was not billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and the rules. We find that CPT code 93042 may be eligible for payment when billed with 
code 93010. The claim information does not show that CPT code 93042 was billed with a modifier suitable for 
payment. 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 electrocardiogram provided on June 21, 2021.