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 you need IRF care. The Plan denied your request. 
The Plan says 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 that review of the available records, you are medically stable and does not need 
physical medicine and rehabilitation physician supervision 3 times per week (at a minimum) for the ongoing 
management of any active or acute exacerbations of chronic medical conditions. At the current functional level, 
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. 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional femur x-ray provided to the enrollee on August 
4, 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 there is no additional documentation supporting an additional study, which was billed and 
remains denied. 
 
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 73552 is Radiologic examination, femur; minimum 2 
views. 
 
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. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found a review of the records showed a 
single two view left femur series - CPT 73552 - which was read and signed by the doctor. No second exam was 
documented. 
 
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 have not been met. Therefore, we decided that the Plan does not 
have to pay for an additional femur x-ray provided to the enrollee on August 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on November 
17, 2021. 
 
You asked the Plan to pay for the dental service. You say that your crown fell out. You also say that the dentist 
had to do an evaluation because of the pain in your mouth. The Plan denied your request. The Plan says 1 
limited oral evaluation is covered per plan year. The Plan also says that the frequency limit has been exceeded. 
 
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 and 1 limited oral evaluation is covered 
per plan year, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral 
evaluation that you received on August 23, 2021.  
 
 
  
 
Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on 
November 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot surgery provided on September 23, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the foot surgery. You say that the provider did not accept Medicare or HMO 
insurance. You say this was an emergency. The Plan denied your request. The Plan says the provider was out-
of-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 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 did not pre-approve the 
item/service at issue.  We found no exception that would require the Plan to pay for these items/services. The record shows the 
surgery was elective. Therefore, we decided that the Plan does not have to pay for foot surgery provided on 
September 23, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary visit provided on October 1, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary visit. You say that the provider relies on facility staff to verify 
eligibility and obtain authorization from the enrollee's insurance. You say the service was medically necessary. 
The Plan denied your request. The Plan says no prior authorization was obtained. 
 
 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 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 domiciliary visit provided on October 1, 2021, 
by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospice long term care services (T2046) provided on 
September 1, 2021, through September 30, 2021. 
 
You asked the Plan to pay for the hospice services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says CPT code T2046 has a status indicator of I. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code T2046 is not supported in the record. Specifically, CPT code T2046 has a status 
indicator of I. This means that CPT code T2046 is not valid for Medicare purposes. Based on this information, 
we decided that Medicare rules for coverage of the hospice services have not been met. Therefore, we decided 
that the Plan does not have to pay for the hospice long term care services (T2046) provided on September 1, 
2021, through September 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an X-Ray examination (73552) provided on July 31, 2021. 
 
You asked the Plan to pay for X-Ray. You say that you are appealing with supporting records. The Plan denied 
your request. The Plan says the denial of payment for this service is correct, because the records do not support 
this code. 
 
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 73552 is radiological examination, femur, minimum 2 
views. 
 
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 X-Ray. Our reviewer says that this code does not meet 
criteria for payment. Our reviewer found the documentation includes two separate claims for 73225 for the 
same date of service and provider, but only 1 unit should be covered for the service provided.  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of X-Ray have not been met. Therefore, we decided that the Plan does not have to 
pay for an X-Ray examination (73552) provided on July 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays 
(D0274) and periodontal maintenance (D4910) provided on November 9, 2021. 
 
You asked the Plan to pay for the dental services. You say that you have limited finances and were not 
informed that these services would not be covered in full beforehand. The Plan denied your request. The Plan 
says they have made partial payment for these services, but at the time of service you met and exceeded your 
$500 annual benefit limit for dental care. You are responsible for any costs that exceed the annual limit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a maximum 
of $500 per year toward the cost of covered supplemental dental care. 
 We looked at the file and the Plans rules. Documentation shows that the Plan has paid the full $500 annual 
allowance for your dental care in 2021, and you are being asked to pay the remaining charges. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided 
that the Plan does not have to pay any additional amount for the periodic oral evaluation (D0120), bitewing x-
rays (D0274) and periodontal maintenance (D4910) provided on November 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
October 18, 2021. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you feel that this service should 
be paid for. The Plan denied your request. The Plan says this service exceeds the frequency limitation in 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, comprehensive oral evaluation 
(D0150) is limited to one procedure every three plan years.  
 The record shows that you received a comprehensive oral evaluation (D0150) on June 8, 2021 and your 
comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we decided that the Plan does 
not have to pay for the comprehensive oral evaluation (D0150) provided on October 18, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from September 7, 202, to October 6, 2021. 
 You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says there was no daily skilled nurse or therapist need. 
 
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 services. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are no identifiable skilled therapy service needs. The enrollee did not require skilled 
nursing or therapy services on a daily basis. The enrollee did not meet severity of illness or intensity of service 
criteria for an inpatient basis in a skilled nursing facility 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) services provided to the enrollee from September 7, 202, to 
October 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for progressive lenses provided on November 9, 2021. 
 
You asked the Plan to pay for progressive lenses. The Plan denied your request. The Plan says you have 
exhausted these benefits as of October 6, 2020. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan 
covers these services every 2 years. 
 
 
  
 
We looked at the file and the Plan's rules. The file shows that you have exhausted the eyewear benefit as of 
October 6, 2020. Based on this information, we decided that the Plan's rules for coverage of progressive lenses 
have not been met. Therefore, we decided that the Plan does not have to pay for progressive lenses provided on 
November 9, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a routine electrocardiogram provided on September 9, 2021. 
 
You asked the Plan to pay for a routine electrocardiogram. The Plan denied your request. The Plan says you 
can get your care from an out-of-network provider, however in most cases that provider must be eligible to 
participate in Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
 
 
 
 
 
  
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for a routine 
electrocardiogram provided on September 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for hearing aids provided on September 1, 2021. 
 
You asked the Plan to reimburse you for the hearing aids. You say that you did not want to use your 
supplemental hearing benefits. The Plan denied your request. The Plan says the hearing aids were purchased 
from an out-of-network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you see a Plan hearing vendor provider. 
 
We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plans 
hearing vendor provider. Based on this information, we decided that the Plan's rules for coverage of the hearing 
aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids 
provided on September 1, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound provided on September 23, 2021. 
 
You asked the Plan to pay for the services provided. You say that the medical records support the charges 
billed. 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. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. We find that CPT code 76700 may be eligible for payment when billed wit 
CPT code 93976. The claim information does not indicate the code at issue was billed with a modifier suitable 
for payment. 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 abdominal ultrasound 
provided on September 23, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport provided on 
August 10, 2021. 
 
You asked the Plan to pay for ambulance response and treatment, no transport. The Plan denied your request. 
The Plan says the Medicare ambulance benefit is a transport benefit. If no transport of a Medicare beneficiary 
occurs, then there is no Medicare covered services. 
 
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 August 10, 2021. 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 ambulance response and treatment, no transport 
provided on August 10, 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 the enrollee needs short term rehabilitation to 
function normally. You say that the enrollee is not currently getting the proper services needed. The Plan 
denied your request. The Plan says the guidelines for coverage of SNF care have not been met. The Plan says 
that the enrollee can receive the care needed in another 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 evidence the enrollee requires 
killed nursing services. The records do not show the need for intravenous medications, new tube feeding or 
ostomy care, or daily complex wound care. The records do show that the enrollee requires skilled therapy 
services, however there is no need for these services to be provided on a daily basis. There is no documentation 
that the enrollee requires the services on an inpatient basis, only in a SNF setting. Services in the home with 
home health care or in a long-term care facility on a part time basis appear appropriate 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 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultrasound (76705) provided on November 1, 2021. 
 
You asked the Plan to pay for an ultrasound. You say that the enrollee had multiple exams. The Plan denied 
your request. The Plan says this is 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 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 an ultrasound (76705) provided on November 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglasses provided on November 9, 2021. 
 
You asked the Plan to pay for the eyeglasses. The Plan denied your request. The Plan says the member does not 
have out-of-network vision benefits. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan 
covers these services when provided through a network optical provider. 
 We looked at the file and the Plan's rules. The file shows that the eyeglasses were not provided through the 
Plans network optical provider. Based on this information, we decided that the Plan's rules for coverage of the 
eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses provided  
on November 9, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on November 23, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for laboratory services provided on November 23, 2020.