Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the oral exam (D0120) and prophylaxis 
(D1110) provided on June 28, 2021. 
 
You asked the Plan to pay an additional amount for the dental services. You say that you were completely 
unaware that that the office was out of network. You say that you had been going to this office for 2 years 
under a different policy with no issues. You say that had you known, you would have gone to elsewhere. You 
also say that this should be covered because you were not aware. The Plan denied your request. The Plan says 
the provider in this case is out of network. The Plan says that the claim was paid in full based on the allowed 
amount. 
 
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. 
 We looked at 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. Specifically, the file shows that the provider in this case is 
out of network. The Evidence of Coverage clearly states that you are responsible for the difference between the 
in network fee and the submitted amount for out of network services. The record shows that the Plan paid the 
full allowed amount for the services you received. Therefore, we decided that the Plan does not have to pay an 
additional amount for the oral exam (D0120) and prophylaxis (D1110) provided on June 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, 
E2313, E2377) for the enrollee. 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee's upper limb strength and function are adequate for the member to be 
able to control the power options using their own switches which are included in the allowance of these power 
options. 
 
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 pre-approve the accessories. Our reviewer says that 
the requested accessories are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the medical records provided, there is no documentation that the enrollee meets Medicare criteria for this request for the additional power wheelchair accessories (E2311, E2313, E2377). A 
medical visit note of 08/25/2021 reports 5/5 right upper extremity strength and 4/5 left upper extremity strength 
thus indicating adequate strength to control the power options with their own switches.  
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377) for the enrollee.
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 this is medically necessary. The Plan denied your 
request. The Plan says the requested therapies can be provided at a lower level of care. 
 
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 acute encephalopathy, falls, and non-ST-elevation myocardial infarction (NSTEMI). 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 medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. There is not a reasonable expectation that this 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture. 
 
You asked the Plan to pre-approve acupuncture. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that effective for services performed on or after January 
21, 2020, CMS will cover acupuncture for Medicare patients with chronic Lower Back Pain (cLBP). 
 
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 acupuncture. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the limited provided records did not clearly 
show that the low back pain was chronic for at least 12 weeks to meet NCD coverage criteria for acupuncture 
treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acupuncture have not been met. Therefore, we decided that the Plan does not 
have to pre-approve acupuncture.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vascular study coded 93976 provided on July 31, 2021. 
 
You asked the Plan to pay for the vascular study. 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 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 the 
vascular study is a column II code to column I code 76856. 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 the vascular study coded 93976 provided on July 
31, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility services for the enrollee.
You asked the Plan to pre-approve skilled nursing facility admission. You say that this admission is medically
necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. The QIC
overturned the Plans denial. The Plan requested a reopen and provided additional information.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for skilled nursing
facility services. The Physician Reviewer determined that inpatient skilled nursing facility care is
medically necessary. Our physician reviewer found that the enrollee's weight bearing status was advanced on
April 9, 2021. At that time, the enrollee did not have documented skilled nursing needs, but she did have
documented skilled therapy needs. Daily skilled services were required to establish a maintenance program,
prevent deterioration of the enrollee's condition and/or improve her overall strength and endurance.
The Plan argues that, by the time of the determination on April 20, 2021 the enrollee was already ambulating
50 ft to 150 ft with a wheeled walker and contact guard assistance, transfers were contact guard assistance;
grooming, eating and dressing her upper body were all independent; set up assist for toileting and moderate
assist for lower body dressing. Her Medical conditions were all stable. Skilled nursing level of care exceeded
her medical need at the time of the request. The change in weight bearing status on April 9th was not enough
reason to increase her level of care as she did not require daily skilled care, since she had significant functional
gains with Part B services. Long term care was the appropriate level based on her medical needs and condition.
Our Medical Director has determined the Plan is correct in this case. The documentation does not support that
the enrollee in this case required skilled nursing or skilled therapy services (or a combination of these services)
on a "daily basis" on 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
skilled nursing facility admission have not been met. Therefore, we decided that the Plan does not have to preapprove
skilled nursing facility services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a tangential biopsy of skin (11102) 
rendered on July 6, 2021. 
 
You asked the Plan to waive the copayment for a tangential biopsy of skin. You say that you have had this 
issue before and the last time this happened, you were told that you need a referral for the facility so that you 
are not charged. You also say that the last time this happened, you got the referral and did not have to pay the 
bill in the end. You also say you want this appealed because you believe the office incorrectly billed the Plan. 
The Plan denied your request. The Plan says you were charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment for each Medicare-covered outpatient surgery in an ambulatory surgical center or hospital 
outpatient facility.  
 
You have been asked to pay a $350 copayment for a tangential biopsy of skin. A tangential biopsy of skin falls 
within the Outpatient Surgery, including services provided at Hospital Outpatient Facilities and Ambulatory 
Surgical Centers 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 tangential biopsy 
of skin (11102) rendered on July 6, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy services provided by an occupational 
therapy assistant on May 13, 2021. 
  You asked the Plan to pay for the occupational therapy services. You say that the medical records required to 
reprocess the denied claim are attached. The Plan denied your request. The Plan says the code is not 
appropriate for the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of an occupational therapy assistant 
(OTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, 
because they do not meet the qualifications of a therapist. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the occupational therapy services have not been met. Specifically, the billing provider is a 
physician assistant, and not a licensed therapist. As such, OTA services cannot be paid incident to this 
provider's professional services. Therefore, we decided that the Plan does not have to pay for occupational 
therapy services provided by an occupational therapy assistant on May 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that a transfer is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not have clinical conditions that cannot be 
appropriately treated in the current hospital. 
 
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 record indicates that the enrollee has had prolonged hospital course due to 
hypoxic respiratory failure, acute kidney failure, and encephalopathy. The medical record does not indicate that 
the enrollee requires services that he is not currently receiving but that would be available at the LTACH 
facility. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ophthalmology services provided on 
July 26, 2021. 
 
You asked the Plan to waive the copayment for the ophthalmology services. You say that you went for a 
routine yearly eye exam, but you were charged a specialist copay of $35. You say you should not have to pay 
because it was no different from any other exam you have had. The Plan denied your request. The Plan says 
you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for a medical eye exam.   
You have been asked to pay a $35 copayment for the ophthalmology services. The record shows that the 
services provided went beyond the scope of a routine eye exam. The record shows your visit included a 
diagnosis of cataracts and a discussion of surgery. These ophthalmology services fall within the Vision Care 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for the ophthalmology services 
provided on July 26, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided by a physical therapist on 
March 2, 2020. 
  You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-
contracted providers at the preferred provider rate if services are not available from preferred providers. You 
say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your 
request. The Plan says the records do not support the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that services of a physical therapist billed as services 
incident to a physician/non-physician practitioner?s service must meet all incident requirements.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner. As such, physical therapy services cannot be paid incident to this provider's professional services. 
Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical 
therapist on March 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 heavy-duty power wheelchair (K0825). 
 
You asked the Plan to pre-approve a Group 2 heavy-duty power wheelchair. You say that the requested item is 
a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for 
the requested item have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Group 2 heavy-duty power 
wheelchair. Our reviewer says that the item at issue is not medically reasonable and necessary in this case. Our 
physician reviewer found that the documentation indicates the enrollee has a mobility deficit that impairs 
MRADLs in the home.  
 The documentation states the enrollee is unable to use an assistive device such as a manual wheelchair due to 
fatigue and weakness but there is no detailed upper extremity neuromuscular evaluation or gait evaluation. 
However, the documentation does not reveal a home assessment indicating that the enrollee can safely 
maneuver a K0825 in the home. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Group 2 heavy-duty power wheelchair have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Group 2 heavy-duty power wheelchair (K0825).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (87481, 87640, 87653, 87798) provided 
on November 6, 2020. 
 
You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan 
denied your request. The Plan says this was not billed correctly. 
 The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS).  
 
We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent 
laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we 
decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that 
the Plan does not have to pay for laboratory services (87481, 87640, 87653, 87798) provided on November 6, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Snoreguard appliance provided on May 19, 2021, by a 
supplier not enrolled in the Medicare program. 
 
You asked the Plan to pay for a Snoreguard appliance. You say that you were told that the charge would be 
paid by the Plan. The Plan denied your request. The Plan says rules for payment have not been met because the 
supplier of the item at issue is not enrolled in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the supplier at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a Snoreguard appliance provided on 
May 19, 2021, by a supplier not enrolled in the Medicare program.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99308 x 2) 
rendered by the out-of-network (OON) provider on June 4, 2021 and June 7, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without 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 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 Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services 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 subsequent nursing facility care, per day (99308 x 2) rendered by the out-of-
network (OON) provider on June 4, 2021 and June 7, 2021.