Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied your request. The Plan says that the coverage criteria has 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 the enrollee does not have complex nursing or rehabilitation needs. Medically necessary care can be provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee requires 24-hour care, and you would 
like a review for coverage based on medical necessity. The Plan denied your request. The Plan says the 
enrollee does not meet coverage guidelines for admission to a SNF. 
 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have documented skilled nursing or skilled therapy needs. Daily 
skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of 
the enrollees condition. The enrollees care needs are custodial and 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 SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2740) and core buildup (D2950) for tooth #8, 
#9, #10. 
 
You asked the Plan to pre-approve the dental services. You say that the existing fillings on the teeth have cause 
active recurrent decay. The Plan denied your request. The Plan says the criterion for the dental benefit requires 
that 50% of the top of the tooth to be missing and or 3 surfaces of decay were not met. 
 
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 the dental 
services when the services are medically necessary and reasonable.  
 
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 dental services. Our reviewer says 
that the documentation provided does not meet the criteria for coverage for core buildup (D2950) and crown 
restorations (D2740) for tooth #8, #9 and #10. Our physician reviewer found documentation indicates that there 
does not appear to be significant coronal breakdown due to caries or fracture of teeth #8, #9 and #10 to warrant 
core buildup and crown restorations. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve crowns (D2740) and core buildup (D2950) for tooth #8, #9, #10.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the walking boot (L4361) provided on March 17, 2022.

You asked the Plan to pay for procedure code L4361. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. The rules say that claim lines billed with codes without a KX, GA or GZ modifier will be rejected as missing information.

We looked at the file and Medicare rules. The file shows that the services were not billed with the required KX, GA, or GZ modifier. Therefore, we decided that the Plan does not have to pay for the walking boot (L4361) provided on March 17, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lidocaine (CPT code J2001). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says using this medicine for pain is not a standard practice. The Plan states treating pain 
with this medicine is still under investigation and there is not enough evidence to prove this is a good treatment 
for pain. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 the medication. Our physician reviewer 
found the Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's 
specific clinical condition. The Medicare approved drug compendia do not contain a supportive citation for the 
use of the requested drug in the enrollee's specific clinical situation. The elements of the coverage criteria are 
not satisfied. 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 medication have not been met. Therefore, we decided that the 
Plan does not have to pre-approve lidocaine (CPT code J2001).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray provided on June 30, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for an x-ray. You say that this should be covered. The Plan denied your request. The 
Plan says there was no preauthorization by a primary care provider (this is different than a referral) for an out-
of-network (OON) provider or facility, and this was not an emergency. Therefore, the decision is upheld. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal.  The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to 
pay for these items/services. Therefore, we decided that the Plan does not have to pay for an x-ray provided on 
June 30, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit, and inpatient 
hospital services provided from November 18, 2020, to November 23, 2020. 
 
You asked the Plan to waive the copayment for an emergency room visit and inpatient hospital services. You 
say that the services were medically necessary and should be covered. 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 $90 for 
emergency care and a $250 copayment for inpatient hospital care. 
 
You have been asked to pay a $1,340 copayment for an emergency room visit and inpatient hospital services. 
These services fall within the emergency care and inpatient hospital care benefit categories. Please see the next 
page for a breakdown of your cost-share. 
 You have been asked to pay a $90 copayment for the emergency care and then you were admitted to inpatient 
status. The copayment for inpatient hospital services is $250 per day for the first six days ($250 copayment  5 
days of service = $1,250 + $90 copayment for emergency care = $1,340). 
 
Therefore, we decided that the Plan does not have to waive the copayment for an emergency room visit, and 
inpatient hospital services provided from November 18, 2020, to November 23, 2020.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for 36140. We decided that the Plan does not have to pay for 75710.  
 
You asked the Plan to pay for angiography, extremity, unilateral, radiological supervision and interpretation 
and introduction of needle or intracatheter, upper or lower extremity artery provided to the enrollee on June 20, 
2022. You say that this should be paid for. The Plan says that these denied codes are inclusive to other billed 
codes.  
We decided that the Plan has to pay for 36140.  
 
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 36140 is "Introduction of needle or intracatheter, upper or 
lower extremity artery." 
 
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 for CPT 36140. Our reviewer says that there is 
satisfactory documentation that the extremity artery was indeed accessed as described in the operative note. 
Therefore, CPT 36140 is appropriately coded. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
36140.  
 
We also decided that the Plan does not have to pay for 75710. 
 
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 75710 is "Angiography, extremity, unilateral, 
radiological supervision and interpretation." 
 
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 for CPT 75710. Our reviewer says that there is 
inadequate documentation to support coverage. The description of the angiogram is very limited and does not 
demonstrate the level of work to justify coding for the supervision and interpretation of a lower extremity 
angiogram. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 75710 have not been met. Therefore, we decided that the Plan does not have to 
pay for 75710. 
 
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: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room (ER) services rendered on June 18, 2022.

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 this claim is a duplicate of a previously paid claim and was correctly denied.

The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. However, such denials may be appealed.

We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were reimbursed by the Plan on July 14, 2022. Comparison of the two claims shows these are exact duplicates. There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for these services have not been met. Therefore, we decided that the Plan does not have to pay for the emergency room (ER) services rendered on June 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost-share for an injection and specialist visit provided on June 1, 2022.

You asked the Plan to reduce the cost-share for an injection. You say that you were unaware how much an injection would cost, and you would like the cost to be reduced. You say that no one advised you on the cost or to contact the Plan to check on coverage. 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 20% coinsurance for all other Medicare-covered Part B drugs and a $25 copayment for services obtained from a specialist. 


You have been asked to pay a total of $438.76 for an injection. The total includes a $25 copayment for specialist services and $413.76 coinsurance, which is 20% of the allowed amount for an injection ($2,068.80 allowed x 20% = $413.76). The specialist service falls within the Physician/Practitioner Services, Including Doctor's Office Visits, benefit category. The injection falls within the Medicare Part B Prescription Drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the cost-share for an injection and specialist visit provided on June 1, 2022. 

Your complaint about not being informed of the injection cost is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pain relief office visit provided on April 11, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for a pain relief office visit. You say that this should be covered. The Plan denied 
your request. The Plan says there was no preauthorization by a primary care provider (this is different than a 
referral) for an out-of-network (OON) provider or facility, and this was not an emergency. Therefore, the 
decision is upheld. 
 
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 a pain relief office visit provided on April 11, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that plans may choose the networks of providers available to enrollees and may require enrollees to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 1, Section 20.2.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.  

Explanation of decision

We decided that the Plan does not have to pay for the medical eye examination and evaluation, with initiation or continuation of diagnostic and treatment program (92012) provided on July 8, 2022, by an out-of-network (OON) provider.

You asked the Plan to pay for the vision services. You say that the enrollee was in a nursing home setting. You say that the enrollee did not have the option to choose an in-network provider. You also say that the service should be paid. The Plan denied your request. The Plan says prior authorization was not 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 provider in this case is not a network provider with the Plan. The facility where the enrollee resides is not a network provider either. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical eye examination and evaluation, with initiation or continuation of diagnostic and treatment program (92012) provided on July 8, 2022, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for skilled nursing facility (SNF) services provided from September 15, 2021, to September 30, 2021.

You asked the Plan to pay for SNF care. You say that these services were pre-approved, and this claim was billed accurately to the services provided. The Plan denied your request. The Plan says that this claim must be re-submitted with the PDPM HIPPS code which was pre-approved.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. We find that the Plan did not submit a compelling denial rationale in this case. The Plan has attested that the SNF services were authorized with a HIPPS code that was calculated at the time that the approval was requested. Based on how the HIPPS code is calculated, however, it is not reasonable to expect or require that the code requested for authorization be the code that is billed. The HIPPS code billed must correspond to the enrollee's actual condition and the services actually rendered during the statement period of the claim. It would therefore be expected that the billed code would differ from a code that was estimated prior to the services being rendered. The Plan has not made any argument that any of the digits of the billed HIPPS code are incorrect or not supported, only that the code as a whole, was not approved. We find that this denial of payment has not been substantiated. Therefore, we decided that the Plan has to pay for skilled nursing facility (SNF) services provided from September 15, 2021, to September 30, 2021. 

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 pay for the debridement (CPT code 97598) provided on June 13, 2022.

You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as billed.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. CPT code 97598 was not billed with an appropriate primary code that is not eligible for payment to the same practitioner for the same enrollee on the same date of service; we find that Medicare rule for payment for CPT code 97598 has not been met. Therefore, we decided that the Plan does not have to pay for the debridement (CPT code 97598) provided on June 13, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for an additional unit of mechanical traction therapy (97012)
provided on June 8, 2022.

You asked the Plan to pay for an additional unit of mechanical traction therapy. You say that this was a
separate service. The Plan denied your request. The Plan says a second unit of this code is not payable.

The Plan must follow Medicare rules. Medicare rules say that interventions described by code 97012 should be
reported no more than one unit per code per day per discipline; additional units will be denied.

We looked at the file and Medicare rules. The records show that one unit of 97012 was paid for this date of
service and provider. No records have been submitted that a second code was provided under a separate
discipline. Based on this information, we decided that Medicare rules for coverage of an additional unit of
mechanical traction therapy have not been met. Therefore, we decided that the Plan does not have to pay for an
additional unit of mechanical traction therapy (97012) provided on June 8, 2022.