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

We decided that the Plan does not have to pay for the medical services coded as 64495, 64494 and 64493
provided on May 11, 2021.
You asked the Plan to pay for the medical services as billed. You say that you would like this claim
reprocessed and approved for payment. The Plan denied your request. The Plan says the codes that have been
billed are incorrect for the services that were rendered.
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 64493 is injection(s), diagnostic or therapeutic agent,
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or
CT), lumbar or sacral; single level.
The CPT Code Manual definition of code 64494 is injection(s), diagnostic or therapeutic agent, paravertebral
facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar
or sacral; second level (List separately in addition to code for primary procedure).
The CPT Code Manual definition of code 64495 is injection(s), diagnostic or therapeutic agent, paravertebral
facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar
or sacral; third and any additional level(s) (List separately in addition to code for primary procedure).
We find that CPT codes 64495, 64494, 64493 are not supported in the medical record. Specifically, the medical
services that were performed were radiofrequency ablation services. Radiofrequency ablation is not described
by the billed CPT codes. The correct codes for radiofrequency ablation services would be 64635 and 64636.
Based on this information, we decided that Medicare rules for coverage of the medical services as billed have
not been met. Therefore, we decided that the Plan does not have to pay for the medical services coded as
64495, 64494 and 64493 provided on May 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the maxillary partial denture (D5211) provided on October
19, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the maxillary partial denture. You say that your dentist is in-network, and he has
not been deactivated from the network. The Plan denied your request. The Plan says services performed by an
OON provider are not covered because your healthcare plan does not have OON benefits. The Plan also says
that you did contact the Plan prior to the date of service, however you did not request this treating provider's
status and he is not listed out on the Plan's website.
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, you are responsible for 100% of the
cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay
for the maxillary partial denture (D5211) provided on October 19, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy services provided from
September 22, 2021, to October 8, 2021.
You asked the Plan to waive the copayment for the physical therapy services. You say that the services should
be covered at $10 per visit. 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 $40
copayment for Outpatient rehabilitation services.
You have been asked to pay a $160 copayment for four physical therapy visits ($40 x 4 = $160). Physical
therapy services fall within the Outpatient rehabilitation services 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 physical therapy services provided from September 22, 2021, to October 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for orthopedic surgery provided from
September 29, 2021, to September 30, 2021.
You asked the Plan to reduce the copayment for orthopedic surgery. You say that you stayed overnight at the
hospital and were admitted as an outpatient. You also say you anticipated being admitted as an inpatient and
only having a $100 copayment. 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 $200
copayment for outpatient surgery at an outpatient hospital facility. The contract also says that to be an inpatient,
your provider must write an order to admit you formally as an inpatient of the hospital. The contract says that
even if you stay in the hospital overnight, you might still be considered an outpatient.
The records show you had an outpatient surgery on September 29, 2021. You have been asked to pay a $200
copayment for orthopedic surgery. Orthopedic surgery 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 reduce the copayment for orthopedic surgery provided from September 29, 2021, to
September 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair glide. 
 
You asked the Plan to pre-approve a stair glide. You say that  The Plan denied your request. The Plan says this 
item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient rehabilitation services provided 
from July 16, 2021, to July 24, 2021. 
 
You asked the Plan to waive the copayment for the inpatient rehabilitation services. You say that you were 
admitted to the rehab facility but did not receive therapy that day. 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 $500 
copayment for each hospital stay.  
 
You have been asked to pay a $500 copayment for the inpatient rehabilitation services. Please note that the 
copayment applies to the entire stay. The inpatient rehabilitation services fall within the Inpatient Hospital 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 inpatient rehabilitation services 
provided from July 16, 2021, to July 24, 2021.
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 you require intense physical therapy. The Plan 
denied your request. The Plan says based on Medicare guidelines, the requested IRF services do not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your current medical 
condition does not require intensive physician or nursing supervision in an IRF. You may benefit from 
additional physical and occupational therapy, but the documentation does not reveal that this therapy must be 
only on an intensive level 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the limited oral evaluation (D0140)
provided on October 14, 2021.
You asked the Plan to pay the in network rate for the limited oral evaluation. You say that the dental office
advised they accept your insurance. The Plan denied your request. The Plan says limited oral evaluation is not
listed as a covered service.
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 limited oral evaluation is not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay the in
network rate for the limited oral evaluation (D0140) provided on October 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8mg Ondansetron tablets. 
 
You asked the Plan to pre-approve the Ondansetron tablets. You say that you would like reconsideration 
because the requested drug is medically necessary. The Plan denied your request. The Plan says the requested 
drug is not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve 8mg Ondansetron tablets.  
 
Benefits for the Ondansetron tablets may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0274), prophylaxis (D1110), and oral
hygiene instructions (D1330) provided on September 14, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the bitewing x-rays, prophylaxis, and oral hygiene instructions. You say that you
checked to make sure that the site you were treated at was in-network. You also say that you were willing to
pay more to continue to see your dentist at this site. The Plan denied your request. The Plan says these services
were rendered by an OON provider. The Plan also says that your plan requires you to have services done by a
contracted dentist.
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
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the
bitewing x-rays (D0274), prophylaxis (D1110), and oral hygiene instructions (D1330) provided on September
14, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultra lightweight wheelchair. 
 
You asked the Plan to pre-approve ultra lightweight wheelchair. You say that the enrollee was given a 
wheelchair which is too heavy. The Plan denied your request. The Plan says the denial of authorization for this 
item is correct, because the enrollee has not had an evaluation. 
 
The Plan follows Medicare rules. Medicare rules state that an ultra lightweight wheelchair may be covered 
under certain criteria. 
 
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 ultra lightweight wheelchair. Our 
reviewer says that the enrollee does not meet the Medicare criteria for an ultra lightweight wheelchair. Our 
physician reviewer found the documentation does not indicates that the enrollee has had a specialty evaluation 
performed by a licensed/certified medical professional who has specific training and experience in 
rehabilitation wheelchair evaluations and that documents the medical necessity fort he requested wheelchair 
and its special features. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ultra lightweight wheelchair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an ultra lightweight wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on September 27, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you are not sure why the claim was not 
paid. The Plan denied your request. The Plan says the claim was denied because there was no prior 
authorization to see a non-participating provider. 
 
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 laboratory services provided on September 27, 
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 an office visit provided on July 16, 2021, by an out-ofnetwork (OON) provider.
You asked the Plan to pay for an office visit. You say that another claim was paid, and this claim should not be
denied. The Plan denied your request. The Plan says there was no prior authorization or a referral from an innetwork provider for the enrollee to receive services from an out-of-network provider. The services were also
determined not to be 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 July 16, 2021, by an
out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99335) provided on
September 8, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the domiciliary or rest home visit. You say that you would like this claim to be
reprocessed for payment. The Plan denied your request. The Plan says the services were rendered by a nonnetwork provider. The Plan also says that the services were not urgent or emergent, nor were they 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 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 domiciliary or rest home visit (99335)
provided on September 8, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for LTACH services provided from March 28, 2020, through
June 12, 2020.
You asked the Plan to pay for the LTACH services. The Plan denied your request. The Plan says the criteria for
admission to the LTACH was not met.
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 pay for 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 patient is a 67-year-old female who was admitted to the acute care hospital with Non-STElevation Myocardial Infarction (NSTEMI), recurrent urinary tract infection, anemia complicated by acute
respiratory arrest, pulmonary embolism, hemorrhagic shock, requiring ventilation support, diuresis, and
antibiotics. Towards the end of her hospital stay, the notes describe the enrollee as still anemic but without
evidence of bleeding and tolerance of trach collar on room air but requiring long-term intravenous antibiotics.
The enrollee appeared to be stable and improving, requiring only short-term additional acute care services that
could have safely been administered at the short-term acute hospital. The enrollee did not require services at
the LTACH that were not already available at the short-term acute care facility. There were no services at the
LTACH that the enrollee required that were not already available and covered at the short-term acute care
facility. Transfer to LTACH is not medically necessary as it would not have been clinically advantageous.
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 pay for LTACH services provided from March 28, 2020, through June 12, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychosocial rehabilitation services (H2017) provided
July 1, 2021 to September 29, 2021.
You asked the Plan to pay for the psychiatric services. You say that the medical records provided will show
proof of medical necessity. The Plan denied your request. The Plan says this service is not a covered telehealth
service.
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 H2017 is psychosocial rehabilitation services, per 15
minutes
We find that CPT code H2017 is not supported in the medical record. Specifically, payment is not allowed for
this service because it is not on any of the approved telehealth service codes list. Based on this information, we
decided that Medicare rules for coverage of the psychiatric services have not been met. Therefore, we decided
that the Plan does not have to pay for the psychosocial rehabilitation services (H2017) provided July 1, 2021 to
September 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continued coverage for the bilevel positive airway 
pressure (BiPAP) device (E0470) and related humidifier (E0562). 
 
You asked the Plan to pre-approve the BiPAP and humidifier. You say that you would like reconsideration 
because the requested BiPAP and humidifier are medically necessary. The Plan denied your request. The Plan 
says you do not meet Medicare criteria for coverage of the requested BiPAP. 
 
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 BiPAP and humidifier. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found you have moderate to severe Obstructive Sleep Apnea (OSA), and has been 
on BiPAP. You have had difficulty tolerating the pressure, and do not have symptomatic benefit.  Compliance 
reports do not meet Medicare criteria of at least 4 hrs/night for at least 70% of nights. The most recent clinical 
note indicates that you are using BiPAP about 2.5 hrs/night.  This is insufficient for benefit. Multiple attempts 
have been made to address your intolerance, including reducing the pressure, mask changes, and ramp changes, 
without success. 
 
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 BiPAP and humidifier have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the continued coverage for the bilevel positive airway pressure (BiPAP) 
device (E0470) and related humidifier (E0562).