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

 
We decided that the Plan does not have to pay for the fluoroscopic guidance provided on May 12, 2021. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the rules for 
payment have not been 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. 
In this case, the CPT Code Manual definition of code 77003 is fluoroscopic guidance and localization of needle 
or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or 
subarachnoid) (List separately in addition to code for primary procedure). 
 
We find that CPT code 77003 was not billed with a valid primary procedure. Based on this information, we 
decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that 
the Plan does not have to pay for the fluoroscopic guidance provided on May 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an unlisted dental surgery procedure (41899) and 
anesthesia for an intraoral procedure (00170). 
 
You asked the Plan to pre-approve an unlisted dental surgery procedure and anesthesia for an intraoral 
procedure. You say that the enrollee's past medical history is significant for severe intellectual disability and 
severe anxiety disorder. Due to the enrollee's medical condition, the enrollee will not tolerate treatment in a 
conventional dental setting. The Plan denied your request. The Plan says the enrollee does not have 
supplemental benefit for these specific dental services. 
 
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 pre-approve an 
unlisted dental surgery procedure (41899) and anesthesia for an intraoral procedure (00170).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5225), and a mandibular 
partial denture (D5226) to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve a maxillary partial denture and a mandibular partial denture. You say that 
you feel like this should be approved. The Plan denied your request. The Plan says the requested benefits are 
not covered benefits. 
 
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 pre-approve a 
maxillary partial denture (D5225), and a mandibular partial denture (D5226) to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on December 9, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you have had these services have been covered in 
the past. The Plan denied your request. The Plan says as of January 1, 2021 this provider was no longer in-
network with the Plan, therefore the services were provided out-of-network and were not approved in advance. 
 
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 office visit provided on December 9, 2021 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 inpatient hospital care from November 21, 
2021, to December 2, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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 $360 
copayment per day for days 1-5 of Inpatient hospital care.  
 
   
You have been asked to pay a $1,800 copayment for 5 days of inpatient hospital care ($360 x 5 = $1,800). 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 inpatient hospital care from November 21, 2021, to 
December 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that inpatient services will be 
necessary following the elective surgery. The Plan denied your request. The Plan says this care will not be 
medically necessary following surgery. 
 
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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the patient is a 67-year-old female who is planning a total hip arthroplasty procedure (elective, non-emergent). This is a request for inpatient services following the procedure. She has a 
history of gastroesophageal reflux disease, asthma, history of gastric bypass surgery, osteoarthritis, prediabetes, 
hypertension, and hyperlipidemia. The provided documentation, however, did not reveal an unstable condition 
or other risk factor that would likely require prolonged recovery in the hospital. There was no suggestion from 
the documentation that the patient would require hospital services that would likely cross 2 midnights for this 
typically ambulatory procedure. 
 
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 pre-approve acute inpatient hospital care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 do not require skilled nursing services. 
You do require skilled therapy services. The documentation does not support that it is medically reasonable and 
necessary to provide skilled therapy services on a daily basis. As a practical matter, you do not require the 
necessary services 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by an out-of-
network provider on October 6, 2021. 
 
You asked the Plan to pay for a limited oral evaluation. You say that you would like the Plan to pay for this. 
The Plan denied your request. The Plan says the benefit limit for D0140 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 Plan's coverage rules apply in this case. The Plan covers a limited oral 
evaluation once per plan year.  
 
We looked at the file and Medicare rules. Evidence was provided to show that D0140 was previously provided 
on September 9, 2021. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation have already been met. Therefore, we decided that the Plan does not have to pay for a limited oral 
evaluation (D0140) provided by an out-of-network provider on October 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
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 enrollee with a right hip fracture does not meet the coverage criteria for this 
admission. The enrollee is medically stable and does not need physician close supervision 3 times per week (at 
a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. 
There are no rehab nursing needs identified in the record. At the current functional level, the enrollee does not 
need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with 
multidisciplinary approach to daily therapy in an IRF. IRF admission is not medically necessary based on 
medical stability and lack of medical complexity, and lack of rehab nursing needs and high functional level. 
 
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 4, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you are an in-network provider, and the claim 
should be reprocessed for payment. The Plan denied your request. The Plan says the rendering provider is an 
out-of-network provider and there was no referral from an in-network provider or an approved authorization. 
Also, the service rendered was not urgent or emergent. 
 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 office visit provided on August 4, 2021, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional materials, supplies, and clinical staff time (99072) 
provided on December 24, 2021. 
 
You asked the Plan to pay for additional materials, supplies, and clinical staff time. You say that the services at 
issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment 
have not been 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. 
 
Per the Physician Fee Schedule, CPT code 99072 has a status indicator of B. This means that the payment for 
99072 is always bundled into the payment for another service or procedure. Based on this information, we 
decided that Medicare rules for coverage of additional materials, supplies, and clinical staff time have not been 
met. Therefore, we decided that the Plan does not have to pay for additional materials, supplies, and clinical 
staff time (99072) provided on December 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight test provided to the enrollee on December 3, 
2021. 
 
You asked the Plan to pay for the testing. You say that this was medically necessary. The Plan denied your 
request. The Plan says there is no documentation that this test is being ordered by a licensed psychiatrist or 
neuropsychiatrist, as required by the rules. 
 
The Plan must follow Medicare rules. Medicare rules say that the current evidence does not support the use of 
GeneSight testing. 
 
Medicare does not currently consider the denied testing to be reasonable or necessary. Based on this 
information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the GeneSight test provided to the enrollee on December 3, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency ambulance transportation services (A0429-
RH, A0425-RH) provided on July 22, 2020. 
 
You asked the Plan to pay for the ambulance transport. You say that this claim was denied in error and should 
be reprocessed for payment. The Plan denied your request. The Plan says this service is not supported as the 
enrollee's claim history shows they were inpatient status at the time of transport. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find 
that CPT codes A0429-RH and A0425-RH are not supported in the medical record. Specifically, these services 
were billed as transport from the enrollees home to the hospital. However, the record shows that the enrollee 
was inpatient status from July 21, 2020, to July 29, 2020. Based on this information, we decided that Medicare 
rules for coverage of the ambulance transport have not been met. Therefore, we decided that the Plan does not 
have to pay for the emergency ambulance transportation services (A0429-RH, A0425-RH) provided on July 
22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve the dental items. You say that you are aware of the frequency limit for 
dentures. You say that your lower dentures are broken. You also say that you are concerned that without lower 
dentures, this can cause healthcare issues. The Plan denied your request. The Plan says dentures are covered 
once every 5 plan years. The Plan also says that the frequency limit has been reached. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and dentures are covered once every 5 
plan years, the frequency limit has been reached. The record shows that the Plan paid for dentures that you 
received on May 22, 2019. Therefore, we decided that the Plan does not have to pre-approve a complete upper 
denture (D5110) and a complete lower denture (D5120).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a pelvic ultrasound (76856) provided on 
December 8, 2021. 
 
You asked the Plan to waive the copayment for a pelvic ultrasound. You say that the Plan paid $0 of the cost of 
an ultrasound. You also say that the Plan should pay the allowed amount and your only cost should be the $45 
copayment for a specialist visit. 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 $125 
copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a 
physician's office or at a free standing facility (such as a radiology center or medical clinic).  
 Your contract with the Plan also says that the diagnostic radiology services require specialized equipment 
beyond standard x-ray equipment and must be performed by specially trained or certified personnel,  and an 
example includes ultrasounds.  
 
You have been asked to pay $123, which is less than the $125 copayment for a pelvic ultrasound. A pelvic 
ultrasound falls within the outpatient diagnostic tests and therapeutic services and supplies 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 pelvic ultrasound (76856) provided on December 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care (99308) provided on July 26, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that you have rendered treatment to the 
patient in good faith that the service will get reimburse. You also 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 a non-
participating provider referred to a non-participating provider. The Plan also says that the service performed by 
the non-participating provider was not authorized by the Plan. The Plan also says that they had network 
providers available to perform the services at issue in the appeal.  
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 subsequent nursing facility care (99308) provided 
on July 26, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a transesophageal echocardiography (93313) provided on 
October 22, 2021. 
 
You asked the Plan to pay for a transesophageal echocardiography. You say that you have provided records to 
support the service at issue. The Plan denied your request. The Plan says rules for payment have not been met 
because the code at issue is inclusive to another billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 93313 
is a column II code to column I code 93314. 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 a transesophageal echocardiography (93313) provided on 
October 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone graft at time of implant placement (D6104), 
guided tissue regeneration (D4266 x 4), endosteal implants (D6010 x 4), precision attachment tooth (D6950 x 
4), and overdenture (D5865). 
 
You asked the Plan to pre-approve the dental services. You say that you have had your dentures adjusted 
several times. You say that the dentures do not seem to fit properly in your mouth. You also say that you 
cannot eat properly. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
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 bone graft, guided tissue 
regeneration, implants, precision attachment, and overdenture are not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pre-approve bone graft at time of implant placement 
(D6104), guided tissue regeneration (D4266 x 4), endosteal implants (D6010 x 4), precision attachment tooth 
(D6950 x 4), and overdenture (D5865).