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

 
We decided that the Plan does not have to pay for the computed tomographic angiography (CTA) of the chest 
(71275) provided on July 13, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the CTA of the chest. You say that you would like this claim to be reviewed and 
reprocessed. The Plan denied your request. The Plan says services from non-participating providers are not 
covered unless preauthorized.  
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 the computed tomographic angiography (CTA) of 
the chest (71275) provided on July 13, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH admission is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee's care can be treated in a 
lower level of care such as skilled nursing facility (SNF). 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the caries preventive medicament application (D1355) 
provided on September 13, 2022. 
 
You asked the Plan to pay for the caries preventive medicament application. You say that you believe this 
service should be covered. The Plan denied your request. The Plan says this service is not covered. 
 
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 caries 
preventive medicament application (D1355) provided on September 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional retainer crown (D6752) provided on June 28, 
2022. 
 
You asked the Plan to pay for the additional retainer crown. You say that you feel the Plan should have paid 
50% for the second retainer crown. 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 June 28, 2022. Therefore, 
we decided that the Plan does not have to pay for the additional retainer crown (D6752) provided on June 28, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and 
panoramic x-ray (D0330) provided on September 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that there was more than enough money left in your 
dental reserve to have covered the cost of these services, and you would like all of the services to be covered. 
The Plan denied your request. The Plan says your benefits for the requested services had 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 benefits for the requested services were exhausted on dates of service March 11, 2021, and June 9, 
2022. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation 
(D0140) and panoramic x-ray (D0330) provided on September 23, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study (95810). 
 
You asked the Plan to pre-approve the sleep study. You say that you want to appeal this service because the 
provider's office has not submitted additional information. The Plan denied your request. The Plan says no 
clinical notes were submitted. The Plan also says there is no way to determine medical necessity for this study 
without clinical documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 sleep study have been met. Medical 
records were not provided with this case. The record shows that the Plan made multiple attempts to obtain this 
information, but it was not received. Without medical records, we are unable to determine if the requested 
service is medically necessary. Therefore, we decided that the Plan does not have to pre-approve a sleep study 
(95810).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prefabricated post and core in addition to crown (D2954) 
provided on July 6, 2022. 
 
You asked the Plan to pay for dental services. You say that the provider stated that they had to do a root canal 
and it would be covered, now you received a bill that you should not have to pay. The Plan denied your 
request. The Plan says this service is not covered under your 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. Prefabricated post and core in 
addition to crown (D2954) is not covered under the Plans dental benefits. 
 
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 
prefabricated post and core in addition to crown (D2954) provided on July 6, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on July 19, 2022, and August 12, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you feel 
you should not be responsible for paying for these bills. The Plan denied your request. The Plan says this 
service is not covered under your contract under any normal circumstances. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 19, 2022 to August 12, 2022. The 
ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays 
for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response 
and treatment with no transport (A0998) provided on July 19, 2022, and August 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodontal maintenance (D4910) provided on 
September 7, 2022, by an out-of-network provider. 
 
You asked the Plan to pay more for the periodontal maintenance. You say that you asked if your insurance 
covered this service because you were last seen on February 14, 2022, and were advised it would be covered. 
You also say that you do not understand why this service was denied, and would like to be reimbursed $24.50. 
The Plan denied your request. The Plan says you are responsible for any charged amount above the Plans cost-
sharing amount when your services are received from an out-of-network provider. 
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for the periodontal maintenance (D4910) 
provided on September 7, 2022, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the fitting of spectacle mounted low vision aid (92354). 
 
You asked the Plan to pre-approve the fitting of spectacle mounted low vision aid. You say that this test would 
assist in seeing what kind of progress you are making with the injections. The Plan denied your request. The 
Plan says Medicare does not cover a low vision exam.  
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. 
 
We looked at the file and the Plan's rules. Specifically, low vision aid exams are not a covered benefit. Based 
on this information, we decided that the Plan's rules for coverage of the fitting of spectacle mounted low vision 
aid have not been met. Therefore, we decided that the Plan does not have to pre-approve the fitting of spectacle 
mounted low vision aid (92354).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20936 billed for date of service February 21, 
2022. 
 
You asked the Plan to pay for procedure code 20936. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says procedure code 20936 is considered 
bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code 20936 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 20936 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 20936 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 20936 billed for date of service February 21, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from February 5, 
2022, to February 13, 2022. 
 
You asked the Plan to pay for SNF care. You say that you were told the Plan would continue to pay for the 
SNF stay. The Plan denied your request. The Plan says the enrollee did not meet the Medicare guidelines due to 
the enrollee no longer required skilled services on a daily inpatient basis and the continuation of SNF was not 
medically necessary. 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you did not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You did not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from February 5, 2022, to February 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a podiatry visit provided on September 23, 
2022. 
 
You asked the Plan to waive the copayment for a podiatry visit. 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 $35 
copayment for podiatry services.  
 
You have been asked to pay a $35 copayment for a podiatry visit. This item/service falls within the podiatry 
services 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 podiatry visit provided on 
September 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on December 30, 2021, 
to January 2, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that these 
services were reported appropriately and are supported as billed. The Plan denied your request. The Plan says 
the DRG submitted on this claim is not submitted by the medical records provided. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with pneumonia due to other gram-negative bacteria 
(J15.6). 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 reviewer says that this diagnosis is not supported in the medical record. Our 
physician reviewer found that the enrollee presented with shortness of breath and weakness. She had been 
treated with Azithromycin for a cough. She was treated with supplemental oxygen and intravenous antibiotics. 
Her condition stabilized and improved, and she was discharged on January 2, 2022. The chest computed 
tomography (CT) demonstrated left upper lobe and left lower lobe pneumonia and small left pleural effusion. 
Per Medscape Internal Medicine, gram-negative pneumonias occur most often in individuals who are 
debilitated, immunocompromised, or recently hospitalized. Individuals living in long-term care facilities where 
other residents are intubated are also at risk for these infections. In this case there was no sputum gram stain or 
culture which identified gram negative organisms. There was no documentation of a gram-negative organism in 
the record. The review has determined that the documentation did not support pneumonia due to other gram-
negative bacteria (J15.6).  
 
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 December 30, 2021, to January 2, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lab services (86618) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the lab services. You say that this testing is necessary to find out if you have 
Lyme Disease. The Plan denied your request. The Plan says this testing is available in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the lab services (86618) to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 14, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported as 
billed. The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 of the lab services 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. Therefore, we decided that 
the Plan does not have to pay for lab services provided on June 14, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services requested are medically necessary. The 
Plan denied your request. The Plan says that the inpatient rehabilitation facility (IRF) services you are 
requesting do not meet the requirements for approval. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found The complexity of the patients nursing medical and rehabilitation needs does require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. Given her cardiac status and multiple 
medical issues, the patient would benefit from the intensity of rehabilitation physician and nursing oversight 
provided in the acute inpatient rehabilitation 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for office visit provided on September 7, 2022. 
 
You asked the Plan to waive the deductible for office visit. 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 $130 
deductible for physician/practitioner services, including doctor's office visits. Your out-of-network (POS) 
deductible is $1,500. This is the amount you have to pay out-of-pocket before the Plan will pay the sare for 
your covered medical services.  
 
You have been asked to pay $130 deductible for office visit. This item/service falls within the 
physician/practitioner services, including doctor's office visits 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 deductible for office visit provided on September 7, 2022.