Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service April 18, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 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 76705 
is a column II code to column I code 93976. 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 procedure code 76705 billed for date of service April 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PENS. 
 
You asked the Plan to pre-approve PENS. You say that PENS is medically necessary. The Plan denied your 
request. The Plan says PENS does not meet the Medicare coverage criteria. 
 
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 PENS. Our reviewer says that the 
requested PENS is not considered medically reasonable and necessary. Our physician reviewer found this 
procedure is considered experimental/ investigational. Therefore, the request is deemed not medically 
reasonable or 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 PENS have not been met.  
 
 
  
Therefore, we decided that the Plan does not have to pre-approve PENS.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown (D2740) provided by a participating provider. 
 
You asked the Plan to pre-approve a crown. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that these services have been correctly denied. 
 
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 a crown 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 a crown. Our physician reviewer found 
the medical criteria for D2740 for tooth #2 has been met. 
 
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 a crown have been met. Therefore, we decided that the Plan has to pre-approve 
a crown (D2740) provided by a participating provider. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214) 
 
You asked the Plan to pre-approve 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 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 item or service was exhausted on date of service June 15, 2020. Therefore, 
we decided that the Plan does not have to pre-approve a mandibular partial denture (D5214)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued coverage of oxygen equipment rental (E1392, 
E1390). 
 
You asked the Plan to pre-approve the continued coverage of oxygen equipment rental. You say that continued 
coverage is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that payment for oxygen equipment is limited to 36 
monthly rental payments. 
 
We looked at the file and Medicare rules. Payment for oxygen equipment rental has already been made for 36 
months. Based on this information, we decided that Medicare rules for coverage of the continued coverage of 
oxygen equipment rental have not been met. Therefore, we decided that the Plan does not have to pre-approve 
continued coverage of oxygen equipment rental (E1392, E1390).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for arthrocentesis and methylprednisolone acetate injections 
(20611, J1030) provided on October 11, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the arthrocentesis and methylprednisolone acetate injections. You say that the 
services should be covered as you disagree with the denial. The Plan denied your request. The Plan says the 
services denied correctly as they were non-emergent and 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 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 arthrocentesis and methylprednisolone acetate 
injections (20611, J1030) provided on October 11, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infrared therapy (97026) provided on December 16, 
2021. 
 
You asked the Plan to pay for the infrared therapy. You say that this service was medically necessary. The Plan 
denied your request. The Plan says infrared therapy is considered not reasonable and necessary by Medicare 
and is excluded from coverage. 
 The Plan must follow Medicare rules. Medicare rules say that the use of infrared and/or near-infrared light 
and/or heat is non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the infrared therapy have not been met. Therefore, we decided that the Plan does not have to pay 
for the infrared therapy (97026) provided on December 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on February 17, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that contractors shall pay mitral valve TEER claim 
lines billed with the most recent CPT codes 33418, 33419, and 0345T in a clinical trial only when billed with 
an 8-digit national clinical trial (NCT) number.  
 
We looked at the file and Medicare rules. The services in this case were not billed with an appropriate 8-digit 
NCT number. Based on this information, we decided that Medicare rules for coverage of the services have not 
been met. Therefore, we decided that the Plan does not have to pay for the services provided on February 17, 
2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services provided to the enrollee from June 12, 2021, to 
June 16, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the RAP claim was received more than 30 days from the start of care. 
 
The Plan must follow Medicare rules. Medicare rules say that home health agencies must submit the RAP 
claim no more than five days from the start of care. 
 
The start of care was June 12, 2021. The RAP was submitted on June 16, 2021, which is within the required 
five day period. 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 home health services provided to the enrollee from 
June 12, 2021, to June 16, 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 eye exam provided on March 22, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for eye exam. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 eye exam provided on March 22, 2022, by an out-
of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 19, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on January 19, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided from August 3, 2020, to August 31, 
2020. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says that the 
deadline for submission of the RAP claim was within 5 days of the start of care. 
 
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. 
 
We looked at the file and the rules. The rules show that RAPs must be submitted within 5 calendar days for 
calendar year 2021. However, the services at issue were provided in 2020. The rules do not indicate a 5-day 
rule for the calendar year 2020. The Plan has not made reasonable and diligent efforts to gather and forward to 
us information regarding their decision to deny your request.  Therefore, we decided that the Plan has to pay for 
the home health services provided from August 3, 2020, to August 31, 2020.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 4 power wheelchair and accessories. 
 
You asked the Plan to pre-approve a group 4 power wheelchair and accessories. You say that this is medically 
necessary for your condition. The Plan denied your request. The Plan says there is no information as to why 
you cannot use an equivalent Group 3 power wheelchair. 
 
The Plan must follow Medicare rules. Medicare rules say that Group 4 power wheelchairs have added 
capabilities that are not needed for use in the home. Therefore, if these wheelchairs are provided, they will be 
denied as not reasonable and necessary. Based on this information, we decided that Medicare rules for 
coverage of a group 4 power wheelchair and accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a group 4 power wheelchair and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visits (99213, 99215, 81002) provided on August 9, 
2021, to October 4, 2021. 
 
You asked the Plan to pay for office visits. You say that you do not agree with the over-payment audit for the 
services performed. The Plan denied your request. The Plan says a refund for the payment was requested 
because the enrollee was under hospice coverage during the dates of service. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.   
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Although 
the provider was originally paid for these services, the plan is entitled to a refund because the enrollee was 
enrolled in hospice on August 6, 2021, through October 14, 2021. Therefore, we decided that the Plan does not 
have to pay for office visits (99213, 99215, 81002) provided on August 9, 2021, to October 4, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have waive the copayment for a SNF stay from January 1, 2022, to January 
22, 2022. 
 
You asked the Plan waive the copayment for a SNF stay. You say that the enrollee should not be responsible to 
pay this. The Plan denied your request. The Plan says the cost share was applied 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). The enrollees contract with the Plan clearly says that for a skilled 
nursing facility stay, enrollees must pay $0 per day for days 1 to 20 and $184 per day for days 21 to 100.  
 
 
 The enrollee has been asked to pay $1104 ($184/day x 6 days) for a skilled nursing facility stay. Records 
submitted indicate the enrollee was admitted from December 27, 2021, to December 31, 2021, and used 5 days 
of their 1-20 day copayment. January 1, 2022, to January 15, 2022, used 15 days of their 1-20 day copayment. 
A skilled nursing facility stay falls within the Skilled Nursing Facility (SNF) Care benefit category. This means 
that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing 
is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the 
Plan does not have waive the copayment for a skilled nursing facility (SNF) stay from January 1, 2022, to 
January 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair, group 2 heavy-duty, single power 
option, sling/solid seat/back, patient weight capacity 301 to 450 pounds (K0837) and accessories (E2361, 
E1028, E2310). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the items are medically 
necessary. The Plan denied your request. The Plan says the clinical notes do not show that this enrollee has a 
mobility limitation that cannot be safely and sufficiently be resolved with a rollator walker, therefore, the 
request remains denied as not medically necessary. 
 
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 patients 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 power wheelchair and accessories. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found you have a 
personal mobility deficit that impairs participation in mobility related activities of daily living such as toileting, 
feeding, grooming and bathing in customary locations within the home. There is no documentation that your 
mobility deficit cannot be helped by the use of a walker. Provided records of 05/24/2022 document that you are 
independent with move room to room with your current rollator walker. As of 06/07/2022, you were 
independent with rollator in home and community. A note of 07/22/2022 reported no recent falls. On 
07/28/2022, you walked 120 feet outside your apartment with a rolling walker and you were discharged from 
physical therapy at that time. 
 
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 wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair, group 2 heavy-duty, single power option, 
sling/solid seat/back, patient weight capacity 301 to 450 pounds (K0837) and accessories (E2361, E1028, 
E2310).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 3, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 procedure code 70450 billed for date of service April 3, 2022.
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 the LTACH services are medically 
necessary for the enrollee. The Plan denied your request. The Plan says the records provided do not support 
LTACH services. Based on the enrollee's current needs it is recommend they stay 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 that the enrollee appears to be improving but still somewhat unstable requiring high 
flow oxygen and should only require short-term additional acute care services that can safely be administered 
at the current facility until more stable and appropriate for a lower level of care. The enrollee does not require 
services at the LTACH that are not already available at the current facility. 
 
  There are no services at the LTACH that the patient requires that are not already available and covered at the 
current facility. Transfer to the LTACH is not medically necessary as the patient is not yet stable and as it 
would not be clinically advantageous at this time. Completion of treatment at the current facility is 
recommended. 
 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing/hospice services provided from February 14, 
2022, to March 15, 2022. 
 
You asked the Plan to pay for skilled nursing/hospice services. The Plan denied your request. The Plan says 
original Medicare is responsible for payment. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for skilled nursing/hospice services provided from February 14, 
2022, to March 15, 2022.