Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (L1833, L2397, L2810) 
provided on December 16, 2020. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like this claim 
reprocessed based on the medical documentation. The Plan denied your request. The Plan says this claim has 
denied correctly based on 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. In this case, the medical records provided do not indicate the prescribing physician discussed the ordered durable medical equipment with the enrollee. The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for the durable medical equipment (L1833, L2397, L2810) provided on December 16, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $90 copayment charged for emergency room services 
provided on March 23, 2021. 
 
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct.  The 
Plan denied your request. The Plan says this copayment is a contractual obligation.  
 
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 emergency room services. 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 $90 copayment 
charged for emergency room services provided on March 23, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. 
The Plan says rules for SNF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you are an 84 year old female with thoracic 
compression fracture and urinary tract infection. While there are identifiable skilled therapy service needs, 
there are no identifiable skilled nursing service needs. In addition, you do not require skilled nursing or therapy 
services on a daily basis. In conclusion, you do 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the wound care provided on July 22, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the wound care. You say that 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. The records provided for 
review do not show that the service at issue was urgent or emergent. 
Therefore, we decided that the Plan does not have to pay for the wound care provided on July 22, 2021, 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 glasses fitting provided on May 6, 2021. 
 
You asked the Plan to pay for the glasses fitting. You say that the patient did not have any input in choosing 
who his optometrist would be. You say that the provider performing services in a nursing home is not 
responsible to obtain authorization and the provider should be reimbursed. The Plan denied your request. The 
Plan says the spectacles fitting is not a covered benefit. 
 
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. The Plan covers these services with the purchase of glasses from a network provider. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the glasses fitting have not been met. Therefore, we decided that the Plan does not have to pay for 
the glasses fitting provided on May 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the amalgam (D2160) for tooth # 19 and limited oral 
evaluation (D0140) provided from May 21, 2021, to June 4, 2021. 
 
You asked the Plan to pay for the dental services. You say that you should not owe anything. The Plan denied 
your request. The Plan says 2 fillings are covered per calendar year. The Plan says that the frequency limit has 
been exceeded. The Plan also says that the limited oral evaluation is not listed as a covered service. 
 
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 and fillings are covered, the frequency 
limit has been exceeded. The record shows that the Plan paid for fillings for teeth # 15 and 18 that you received 
on May 21, 2021. Additionally, the limited oral evaluation is not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pay for the amalgam (D2160) for tooth # 19 and limited 
oral evaluation (D0140) provided from May 21, 2021, to June 4, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for testing services provided to the enrollee on March 23, 2021 
and billed under codes 75710 and 75625. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says Medicare billing criteria were not met. 
 
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 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 
these services. Our reviewer says that Medicare billing criteria are not met. Our reviewer found the 
documentation submitted does not meet required criteria. For code 75710, the documentation does not support 
unusual non-overlapping services or has the required modifier.  This procedure is considered part of another 
procedure performed and billed on same day. For code 75625 the procedure report does not document films 
taken by serigraphy, and therefore cannot be confirmed as performed.   We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for testing services provided to the enrollee on March 23, 2021 and billed under codes 75710 and 
75625.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services provided on June 25, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy services. You say that the service was provided with no 
adequate time frame to obtain authorization for the service. The Plan denied your request. The Plan says 
enrollees must receive their medical services from an in-network provider with the exception being urgent or 
emergent services. Non-emergent services with non-contracted providers require prior authorization before 
services being rendered. 
 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 psychotherapy services provided on June 25, 
2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional testing strips. 
 
You asked the Plan to pre-approve additional testing strips. You say that the number of test strips being 
requested is medically necessary for the enrollee. The Plan denied your request. The Plan says the supplies in 
dispute are above the normal dispensing limits. The Plan says that the medical records from the provider 
indicate that the amount already supplied is adequate and more are not needed. 
 
The Plan follows Medicare rules. Medicare rules say that if quantities of test strips or lancets that exceed the 
utilization guidelines are provided and criteria are not met, the amount in excess will be denied as not 
reasonable and necessary. 
 
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 additional testing strips. Our reviewer 
says that the criteria for coverage of additional testing strips have not been met. Our physician reviewer found 
the enrollee has been prescribed 4 strips per day. The enrollee does not seem to be checking that often from the 
blood glucose logs provided and the office notes. It is unclear from the records whether the enrollee would 
need more than 4-5 strips per day, as he is on a 4 shot per day regimen. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional testing strips have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional testing strips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for prophylaxis - adult (D1110) and periodic oral evaluation-
established patient (D0120) provided by an out-of-network provider on July 6, 2021. 
 
You asked the Plan to pay for prophylaxis - adult and periodic oral evaluation. You say that this provider is in-
network. The Plan denied your request. The Plan says the rendering dentist is out-of-network. 
 
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 pay for 
prophylaxis - adult (D1110) and periodic oral evaluation-established patient (D0120) provided by an out-of-
network provider on July 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the service(s) provided between 10:00 PM and 8:00 AM at 
24-hour facility coded 99053 provided on May 2, 2021. 
 
You asked the Plan to pay for the service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility. You 
say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the 
services billed are not 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, the CPT Code Manual definition of code 99053 is service(s) provided between 10:00 PM and 8:00 
AM at 24-hour facility, in addition to basic service. 
 
We find that CPT code 99053 is not supported in the medical record. Specifically, this code has a status 
indicator of "B". A status indicator of B means that payment for this service is always bundled into payment for 
services not specified and no separate payment can be made. Based on this information, we decided that 
Medicare rules for coverage of the service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility have 
not been met. Therefore, we decided that the Plan does not have to pay for the service(s) provided between 
10:00 PM and 8:00 AM at 24-hour facility coded 99053 provided on May 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
July 28, 2021. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must 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 out of network physician services provided to the 
enrollee on July 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on January 20, 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 the services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on January 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the foot orthosis (L3010) provided on June 4, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the foot orthosis. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained for 
these services rendered by an OON provider. 
 
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 foot orthosis 
(L3010) provided on June 4, 2021, by an out-of-network (OON) provider.
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 records provided support the need for IRF care. 
The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The 
Plan says that the enrollee could receive care in another setting. 
 
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. The 
enrollee was admitted for surgical management of a hip fracture after a fall. The enrollee's medical problems 
are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the documentation does support a need for physical and/or occupational therapy, there 
is no documented need for a intensive, multi-disciplinary rehabilitation program. 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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient care provided to the enrollee from May 13, 2020, to 
May 19, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid as billed. The Plan denied 
your request. The Plan says Medicare billing criteria are not met. 
 
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. 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 this service. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer 
found the enrollee had a diagnosis of sepsis, unspecified.  The documentation submitted does clearly support 
the diagnosis of sepsis.  Sepsis is documented in emergency room visit, as well as discharge note. The 
documentation throughout the hospital stay does not include the care and treatment of sepsis.  Although, sepsis 
could be indicated by documentation in the emergency room visit, subsequent care documentation does not 
support a diagnosis of sepsis.  
 
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 care provided to the enrollee from May 13, 2020, to May 19, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. 
The Plan says rules for SNF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that based on the documentation provided, you 
do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You are 
consistently ambulating more than 100 feet. Daily skilled services are not required to establish a maintenance 
program or to prevent deterioration of your condition. Your care needs, as a practical matter, can be provided at 
a lower level of 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on  
December 2, 2020. 
 
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 Medicare denies coverage for all cardiovascular genetic risk assessment panels. 
 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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found Medicare denies coverage for all cardiovascular generic risk profiles. Medicare only cover a lipid panel 
consisting once of a total cholesterol, HDL cholesterol, and triglycerides once every 5 years as cardiovascular 
screening. The review has determined that does not the enrollee meet the criteria for this request. 
 
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 laboratory services provided to the enrollee on December 2, 2020.