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

 
We decided that the Plan does not have to pay for the computed tomography (CT) of the head or brain (70450) 
provided on July 29, 2021.  
You asked the Plan to pay for the CT of the head or brain. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 70450 
and 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 the computed tomography (CT) of the head or brain (70450) 
provided on July 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the thorax CT scan (CPT code 71250) and the abdomen CT scan (CPT code 74150) provided on August 25, 2021.
You asked the Plan to pay for the CT scans. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as billed.
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 71250 is a column II code to column I code 71275. Furthermore, we have confirmed that code 74150 is a column II code to column I code 74174. Therefore, claims have not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the thorax CT scan (CPT code 71250) and the abdomen CT scan (CPT code 74150) provided on August 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99213) provided on July 8, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the unauthorized services rendered were by a non-participating provider. 
The Plan also says that it was determined that the services received were not urgent/emergent, and the member 
does not have out of network coverage for services determined to be non-urgent/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 (99213) provided on July 8, 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 rehabilitation hospital care provided from June 4, 2021, to June 23, 2021.
You asked the Plan to waive the copayment for inpatient rehabilitation hospital care. You say that you spoke with the Plan and were told that you have a zero copayment for rehabilitation, so you should not have been billed for it. 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 $395 copayment each day for days 1 to 5 for Medicare-covered hospital care. Your contract with the Plan also says that Medicare hospital benefit periods do not apply, and for inpatient hospital care, the cost-sharing applies each time you are admitted to the hospital. Your contract with the Plan also says that a transfer to a separate facility type (such as an inpatient rehabilitation hospital or long term care hospital) is considered a new admission. You have been asked to pay a $395 copayment each day for days 1 to 5 for inpatient rehabilitation hospital care, which totals $1,975 ($395 x 5 = $1,975). Inpatient rehabilitation hospital care falls 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 hospital care provided from June 4, 2021, to June 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99212) mechanical traction 
(97012) provided September 9, 2021. 
 
You asked the Plan to pay for the office visit. You say that the medical records provided support the necessity 
of the services in dispute. The Plan denied your request. The Plan says this service is not covered when 
rendered by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the outpatient office visit (99212) mechanical traction (97012) provided 
September 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the POV, group 1 standard, patient weight capacity up 
to and including 300 pounds (CPT code K0800). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says your request is not medically necessary because your records do not show problems 
finishing one or more activities of daily living (ADLs), inability to use cane or walker, inability to use a 
manual wheelchair, the mental and physical capabilities to safely operate the power chair, there is enough room 
in your home to operate assistive device, upper extremity strengths, ability to maintain upright posture while 
seated and safely use a scooter, nor home safety evaluation for use of scooter. The Plan states there is no 
standard written order for this device as required by Medicare. 
 
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 the DME. Our physician reviewer found the documentation indicates you have mobility deficit, but the documentation does not reveal that it 
impairs MRADLs in the home. The documentation does not reveal the deficit is not ameliorated by a walker, 
cane, manual wheelchair. The documentation does not reveal that your home can accommodate the requested 
POV for safe maneuvering and that the requested device will significantly improve MRADLs in the home. The 
documentation does not support the medical necessity of the K0800. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the POV, group 1 standard, patient weight capacity up to and including 300 pounds (CPT code 
K0800).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anterior instrumentation (22845) provided on July 22, 2021. 
 
You asked the Plan to pay for anterior instrumentation 22845. You say that you provided care in good faith and 
payment should be granted. The Plan denied your request. The Plan says the denial of payment for this service is correct, because code 22845 has a procedure-to-procedure (PTP) edit of 1 with code 22853 so is not 
separately payable without an appropriate modifier. 
 
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 22845 
is a column II code to column I code 22853. 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 anterior instrumentation (22845) provided on July 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for trimming of dystrophic nails (CPT code G0127) provided on 
June 29, 2021. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not covered as billed. 
 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 G0127 
is a column II code to column I code 11720. 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 trimming of dystrophic nails (CPT code G0127) provided on 
June 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam and refraction (92004, 92015) provided on 
August 26, 2021. 
 
You asked the Plan to pay for the eye exam and refraction. You say that it was your understanding that when 
these services were provided by an in-network provider, there would be no copayment required. The Plan 
denied your request. The Plan says they have agreed to cover and pay for these services up to the $75 
allowance; however, the provider in this case is not part of the Plan's specified routine vision vendor network 
and you are responsible for the charges that exceed this $75 allowance. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers one routine eye exam with refraction per calendar year. There is a $75 allowance for 
these services. When performed by a provider in the Plans specified routine vision vendor network, the 
charges for these services will not exceed $75. If performed by a provider outside of this specified vendor 
network, you are responsible for any billed amount over the $75 allowance. 
 
We looked at the file and the Plan's rules. The record indicates that the provider in this case is part of the Plans 
medical network but is not part of the Plans specified routine vision vendor network. The services provided 
are covered, and the Plan has paid the full $75 allowance toward the cost of these services. Because this 
provider is not part of the Plans specified routine vision vendor network, you are responsible for the remaining 
cost. Based on this information, we decided that you have been asked to pay the correct amount for these 
services based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay an 
additional amount for the eye exam and refraction (92004, 92015) provided on August 26, 2021.  
 
Your complaint about potential confusion between the Plans medical network and the Plans routine vision 
vendor network is not a valid appeal for medical coverage. This part of your complaint is a grievance that must 
be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite - one surface, posterior (D2391) 
and resin-based composite - two surfaces, posterior (D2392) provided November 22, 2021. 
 
You asked the Plan to pay for the fillings. You say that you would like these services covered. The Plan denied 
your request. The Plan says these services are not covered under your 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. 
 
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 the resin-
based composite - one surface, posterior (D2391) and resin-based composite - two surfaces, posterior (D2392) 
provided November 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visits provided from June 
30, 2021, to July 8, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visits. You say that the services should be 
covered as the services were not good. 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 $35 
copayment for Physician/Practitioner services, including doctor's office visits.  
 
 
 
 You have been asked to pay a $105 copayment for three specialist office visits ($35 x 3 = $105). Specialist 
office visits falls within the Physician/Practitioner services, including doctor's office visits 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 specialist office visits provided from June 30, 2021, to July 
8, 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 the services can be safely received in other settings, for example: a skilled nursing 
facility, home with home health services, or home with outpatient therapy. 
 
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 documentation does not support that the complexity of the enrollee's nursing, medical and rehabilitation needs requires an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The documentation does not support that the enrollee requires at least 3 hours a day /5 days 
a week, or 15 hours over 7 consecutive days, of therapy services. There is not a reasonable expectation that the 
enrollee would be able to fully participate in and benefit from the intensive rehabilitation therapy program that 
would be provided in the 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided on
August 26, 2021.
You asked the Plan to waive the copayment for the emergency room visit. You say that the services should be
covered as you were informed that any COVID-19 related issues would be covered in full. The Plan denied
your request. The Plan says the cost-sharing applied correctly, the waiver for COVID-19 related services
expired on May 31, 2021.
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 $90
copayment for Emergency care.
You have been asked to pay a $90 copayment for an emergency room visit. 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 an emergency room visit provided on August 26, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (93976) provided October 5, 2021. 
 
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the code billed shares a bundled relationship with another code billed.  
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 93976 
is a column II code to column I code 76856. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for radiology services (93976) provided October 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says there is no requirement for services that cannot be given at a lower level of 
care. 
 
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 enrollee appears to be improving and requires only short-term additional acute 
care hospital services that can safely completed at the current facility.  The enrollee does not require services at the LTACH that are not already available at the current 
facility. Transfer to LTACH is not medically necessary as it would not be clinically advantageous. Transfer to a 
lower level of care may be considered when treatment has completed. 
 
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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extractions to be provided in an outpatient setting. 
 
You asked the Plan to pre-approve dental services. You say that the enrollee requires dental extraction to be 
done at the hospital due to medical issues. You also say that this has been covered for the enrollee in the past. 
The Plan denied your request. The Plan says routine dental services are not covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of the enrollees teeth or the structures directly supporting the enrollees teeth. These are dental services that 
are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve 
extractions to be provided in an outpatient setting.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), panoramic x-ray 
(D0330), and prophylaxis (D1110) provided on September 21, 2021. 
 
You asked the Plan to pay for the periodic oral evaluation, panoramic x-ray, and prophylaxis. You say that the 
Plan does cover out-of-network providers. You also say that you have previously seen this provider and the 
claim was processed correctly. The Plan denied your request. The Plan says your dentist has to submit their tax 
identification (ID) number in order for your claim to process. The Plan also says that this was not included in 
your claim, and the claim cannot process without this information. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the periodic oral evaluation (D0120), 
panoramic x-ray (D0330), and prophylaxis (D1110) provided on September 21, 2021. have not been met. We 
found that the provider's Tax Identification (ID) was not submitted. The provider's Tax ID needs to be 
submitted in order for the claim to process. Therefore, we decided that the Plan does not have to pay for the 
periodic oral evaluation (D0120), panoramic x-ray (D0330), and prophylaxis (D1110) provided on September 
21, 2021.