Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 17, 2022. 
 
You asked the Plan to pay for an office visit. You say that this service was medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on March 17, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prostate cancer screening provided on November 07, 2022. 
 
You asked the Plan to pay for prostate cancer screening. You say that the enrollee has been seeing this provider 
for a long time, and you would like reimbursement for these services. The Plan denied your request. The Plan 
says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for prostate cancer 
screening provided on November 07, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on November 15, 2022. 
 
You asked the Plan to pay for laboratory services. You say that the enrollee is in a nursing facility and does not 
have the option on what lab service to use. The Plan denied your request. The Plan says that unauthorized, out-
of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on November 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 82747, 84436 and 84480 billed for date of 
service September 15, 2022. 

You asked the Plan to pay for procedure codes 82747, 84436 and 84480. You say that these services are supported in the medical records. The Plan denied your request. The Plan says the payment for codes 84436 
and 84480 is bundled into payment for codes 84439 and 84481. In addition, there is a more appropriate code to 
report the services billed with code 82747. 
 
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 84436 
is a column II code to column I code 84439 with a modifier indicator of 0, and 84480 is a column II code to 
column I code 84481 with a modifier indicator of 0. The column II codes are therefore not payable. In addition, 
code 82747 (folic acid, red blood cell) was submitted on this claim. However, the medical records show that 
code 82746 (folic acid, serum) is more accurate in this case. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
82747, 84436 and 84480 billed for date of service September 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft for ridge preservation - per site 
(D7953) provided on January 2, 2023. 
 
You asked the Plan to pay for the bone replacement graft for ridge preservation - per site. You say that you do 
not understand why this typical component of the implant process is not included in that coverage. The Plan 
denied your request. The Plan says this service is not covered under the benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a bone 
replacement graft for ridge preservation - per site (D7953) provided on January 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation and intraoral x-ray (D0150, 
D0210) provided on December 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. 
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a comprehensive oral evaluation and intraoral x-ray (D0150, D0210) provided on December 21, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for observation care provided on August 17, 2022. 
 
You asked the Plan to pay for observation care. You say that the enrollee did not have a choice to the provider 
that was able to see them. The Plan denied your request. The Plan says that unauthorized, out-of-network care 
is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for observation care 
provided on August 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to approve the acute inpatient hospital level of care. 
 
You asked the Plan to approve acute inpatient hospital care. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the surgery is approved but the inpatient admission is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  
 
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 approve acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient care are met. Our physician reviewer 
found that the approved procedure is not on the inpatient-only list. The enrollee has had a preoperative 
evaluation and there is not a reasonable expectation that she will require at least two midnights of inpatient 
hospital care for the approved procedure. The inpatient admission is not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to approve the acute inpatient hospital level of care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee is receiving medically necessary acute and/or critical care. The enrollee does not have clinical conditions that cannot be appropriately treated in the current hospital, and there are no issues for which LTACH may offer a therapeutic advantage.

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 requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only
on an inpatient basis.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service October 14, 
2022. 
 
You asked the Plan to pay for procedure code 99053. You say that the patient was seen twice on the same day 
by two different providers. The Plan denied your request. The Plan says procedure code 99053 is considered 
bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service October 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye exam provided on December 12, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the eye exam. You say that you were informed that these services were covered. 
The Plan denied your request. The Plan says unauthorized, out-of-network care is not covered. 
 
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 eye exam provided on December 12, 2022, by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power tilt seating system (E1002). 
 
You asked the Plan to pre-approve a power tilt seating system. 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 power wheelchair accessories are covered when 
certain criteria are met. 
 
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 power tilt seating system. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found provided records 
from the enrollee's physician do not support that the patient is high risk for skin breakdown, has a history of 
pressure ulcer(s) or has had skin flap surgery. Records do not document the enrollee performs bladder self-
catheterization or that the enrollee has increased muscle tone or spasticity to meet criteria for the power tilt 
and/or recline. 
 
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 power tilt seating system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a power tilt seating system (E1002).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hospital bed, extra heavy duty, extra wide, with 
weight capacity greater than 600 pounds, with any type of side rails, without mattress (E0302x10). 
 
You asked the Plan to pre-approve an extra heavy duty hospital bed. You say that the enrollee needs the 
requested items to avoid further admission into the hospital. The enrollee has severe heart failure and limited 
mobility. The Plan denied your request. The Plan says the enrollee must weigh more than 600 pounds for this 
type of hospital bed. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Medicare rules say the enrollee must weigh more than 600 pounds to 
qualify for the requested hospital bed. The medical records show the enrollee does not weigh more than 600 
pounds; therefore, the enrollee does not meet criteria for approval of the requested hospital bed. Based on this 
information, we decided that Medicare rules for coverage of an extra heavy duty hospital bed have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a hospital bed, extra heavy duty, extra 
wide, with weight capacity greater than 600 pounds, with any type of side rails, without mattress (E0302x10).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections provided on June 8, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for injections. You say that you believe you should be covered for the services. The 
Plan denied your request. The Plan says this was not authorized 
 
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 injections provided on June 8, 2022, by an out-of-
network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) 
provided on September 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that this service was an emergency due the poor 
quality of the previous dental care received. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested service was exhausted on date of service March 4, 2022, and March 25, 
2022. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation - problem focused 
(D0140) provided on September 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endosteal implants (D6010 x 3), cone beam CT capture 
and interpretation (D0367), osseous, osteoperiosteal, or cartilage graft (D7950), sinus augmentations (D7952 x 
2), general anesthesia first 15 minutes (D9222) and general anesthesia each subsequent 15-minute increment 
(D9223). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says these services are either not covered under your dental plan or your benefit 
for the requested item or service has been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Additionally, the record shows your benefit for dental implants was 
exhausted when the Plan approved two out of the five requested implants. Therefore, we decided that the Plan 
does not have to pre-approve endosteal implants (D6010 x 3), cone beam CT capture and interpretation 
(D0367), osseous, osteoperiosteal, or cartilage graft (D7950), sinus augmentations (D7952 x 2), general 
anesthesia first 15 minutes (D9222) and general anesthesia each subsequent 15-minute increment (D9223).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient behavior health services provided on May 12, 
2022, to July 15, 2022. 
 
You asked the Plan to pay for outpatient behavior health services. You say that you think that these services 
should be covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for outpatient behavior 
health services provided on May 12, 2022, to July 15, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service October 20, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service October 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the abdomen and pelvis. 
 
You asked the Plan to pre-approve a CT scan. You say that you are requesting reconsideration for the denial of 
a CT scan to follow up on the fracture the enrollee has had in the past. The Plan denied your request. The Plan 
says the request for a CT scan of the abdomen and pelvis is denied as not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 a CT scan. Our reviewer says that the 
CT scan is not medically reasonable or necessary. Our physician reviewer found the Plan approved an MRI of 
the pelvis. Detailed documentation is not evident regarding the need for additional advanced imaging at this 
time. The MRI could be performed, and then re-evaluation to determine the need for additional imaging. No 
compelling rationale is presented, or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a CT scan of the abdomen and pelvis.