Persius/hicric huggingface dataset:
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 the services requested are medically necessary. The 
Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) services you are requesting 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 the enrollee does not require the intensity of services provided at an IRF. The 
enrollees care needs can be met at a lower level of care.  
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital stay provided on July 26, 2022, to July 27, 
2022. 
 
You asked the Plan to pay for inpatient hospital stay. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for inpatient hospital stay 
provided on July 26, 2022, to July 27, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service October 11, 
2022. 
 You asked the Plan to pay for procedure code 76641. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service October 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lens enhancements including progressive lenses, hi index, 
polarization, scratch resistant, and oversize provided on October 20, 2022. 
 
You asked the Plan to pay for lens enhancements including progressive lenses, hi index, polarization, scratch 
resistant, and oversize. You say that the lens enhancements were recommended by the ophthalmologist. The 
Plan denied your request. The Plan says the services are not covered. 
 
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 lenses that are not enhanced. 
 
We looked at the file and the Plan's rules. The Plan rules say that non-covered lens enhancements include anti-
reflective lenses, progressive lenses, photochromic lenses, scratch-resistant lenses, polycarbonate lenses, and 
plano lenses. The record shows that the enhancements you received are among those listed as non-covered. 
Based on this information, we decided that the Plan's rules for coverage of lens enhancements including 
progressive lenses, hi index, polarization, scratch resistant, and oversize have not been met. Therefore, we 
decided that the Plan does not have to pay for lens enhancements including progressive lenses, hi index, 
polarization, scratch resistant, and oversize provided on October 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided on July 20, 2022. 
 You asked the Plan to pay for the billed services. You say that the services were done due to medical necessity. 
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.  
 
In this case, the CPT Code Manual definition of code G0463 is hospital outpatient clinic visit for assessment 
and management of a patient. We find that CPT code G0463 has a status indicator of V and was billed on the 
same claim as code 74177, which has a status indicator of S. If any E&M code that occurs on a day with a type 
S procedure does not have a modifier of 25, then edit 21 applies and the claim is returned to the provider. 
 
The CPT Code Manual definition of code G1004 is clinical decision support mechanism national decision 
support company, as defined by the Medicare appropriate use criteria program. We find that G1004 is not paid 
by Medicare when submitted on an outpatient claim.  
 
We find that CPT codes Q9967, 82565, and 74177 were denied as these services may be eligible for payment 
when other denied line items are corrected. 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 outpatient hospital services provided on July 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on August 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the services requested 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 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 dental 
services on August 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound of the abdominal aorta (76706) provided on 
June 8, 2022. 
 
  You asked the Plan to pay for the ultrasound of the abdominal aorta. You say that you have an abdominal aortic 
ectasia, which requires annual monitoring. You also say that this screening has been done multiple times in the 
past, and you believe there was a coding error. The Plan denied your request. The Plan says you received 
abdominal aortic aneurysm (AAA) screening services on June 15, 2018, and the AAA screening received June 
8, 2022, is excluded from coverage under your plan. 
 
The Plan must follow Medicare rules. Medicare rules say that payment may be made for a one-time ultrasound 
screening for AAA. 
 
We looked at the file and Medicare rules. Specifically, the record shows that you received abdominal aortic 
aneurysm (AAA) screening services on June 15, 2018, and your AAA benefit has been exhausted. Based on 
this information, we decided that Medicare rules for coverage of the ultrasound of the abdominal aorta have not 
been met. Therefore, we decided that the Plan does not have to pay for the ultrasound of the abdominal aorta 
(76706) provided on June 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown and core buildup services (D2950, D2740) provided 
on August 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your $1,000 dental benefit maximum allowance 
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 August 15, 2022. 
Therefore, we decided that the Plan does not have to pay for a crown and core buildup services (D2950, 
D2740) provided on August 15, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service October 24, 
2022. 
 You asked the Plan to pay for procedure code 76641. You say that the records support multiple procedures 
rendered. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service October 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit for a new patient (99203) provided on August 
1, 2022. 
 
You asked the Plan to pay for the evaluation and management service. You say that the enrollee has not been 
seen in the last three years by this provider, nor by a physician with this specialty. You also say that this 
procedure code is eligible for reimbursement. The Plan denied your request. The Plan says the enrollee has 
previously been seen by the same provider within the previous three years. 
 
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 99203 is office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low 
level of medical decision making. When using time for code selection, 30-44 minutes of total time is spent on 
the date of the encounter. 
 
We find that CPT code 99203 is not supported in the medical record. Specifically, the provided documentation 
indicates that the enrollee previously received professional services from this physician and billing group. 
Based on this information, we decided that Medicare rules for coverage of the evaluation and management 
service have not been met. Therefore, we decided that the Plan does not have to pay for the office visit for a 
new patient (99203) provided on August 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portable oxygen concentrator received on November 28, 
2022. 
 
You asked the Plan to pay for the portable oxygen concentrator. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the item received is not a covered benefit.  
The Plan must follow Medicare rules. The rules say that oxygen equipment is covered when rented. Purchased 
oxygen equipment is not covered. Medicare rules also 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. 
 
We looked at the file and Medicare rules. Oxygen equipment is only covered when rented. Purchased 
equipment is not eligible for reimbursement. In addition, the portable oxygen concentrator was received by a 
provider that is not a network provider with the Plan. Based on this information, we decided that Medicare 
rules for coverage of the portable oxygen concentrator have not been met. Therefore, we decided that the Plan 
does not have to pay for the portable oxygen concentrator received on November 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyewear provided on October 8, 2022. 
 
You asked the Plan to pay for the eyewear. You say that the eyeglasses should be covered. You say you needed 
the new prescription after your cataract surgery. The Plan denied your request. The Plan says the claim 
processed correctly, and the $200 benefit was applied.  
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 pays a $200 benefit towards these services. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid $200 towards the eyeglasses. Based on 
this information, we decided that the Plan's rules for coverage of the eyewear have not been met. Therefore, we 
decided that the Plan does not have to pay for the eyewear provided on October 8, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown - porcelain/ceramic tooth #9 (D2740). 
 
You asked the Plan to pre-approve the crown - porcelain/ceramic tooth #9. You say that you feel this service is 
medically necessary. The Plan denied your request. The Plan says there is no medical evidence to support 
medical necessity. 
 
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 crowns - 
porcelain/ceramic tooth #9 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 the crown - porcelain/ceramic tooth #9. 
Our reviewer says that the documentation provided meets the criteria for coverage for a replacement crown 
(D2740) for tooth #9. Our physician reviewer says the documentation indicates that the porcelain has fractured 
from the crown presently in place and recurrent caries is present. It is medically reasonable and necessary to 
replace the crown to provide good function and to prevent the spread of the caries. 
 
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 - porcelain/ceramic tooth #9 have been met. Therefore, we decided that 
the Plan has to pre-approve a crown - porcelain/ceramic tooth #9 (D2740).  
 
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 waive the copayment for the urgent care visit provided on October 
11, 2022. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that you were informed there was 
no charge for the COVID-19 testing. The Plan denied your request. The Plan says this cost sharing was charged 
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). Your contract with the Plan clearly says that you must pay a $35 
copayment for urgently needed services. 
 
You have been asked to pay a $35 copayment for the urgent care visit. This item/service falls within the 
urgently needed 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 the urgent 
care visit provided on October 11, 2022.
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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the 
documentation does support a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve Intracept. You say that this procedure fills a treatment gap for those patients 
that do not receive adequate relief from traditional conservative methods and do not have instability to indicate 
that fusion is appropriate. The Plan denied your request. The Plan says there is insufficient evidence of the 
efficacy of this procedure. 
 
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 Intracept. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case, there are multiple possible sources of significant pain generation. The chronic right 
lumbar pain, the noted pain-aggravating factors, pain-relieving factors, along with the absence of an objective 
examination were/are all non-specific to any pathologic entities. Documentation is lacking regarding 
reasonably detailed evidenced findings supportive of the spinal vertebral bodies as being the overwhelming 
primary generators of the enrollee's chronic persistent pain. There is no compelling rationale or extenuating 
circumstance noted to support the necessity of this request as an exception to guidelines.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Intracept procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical pathology provided on September 14, 2022, by an 
OON provider. 
 
You asked the Plan to pay for surgical pathology. You say that the enrollee does not come to your laboratory, 
so the enrollee is not using out-of-network benefits. The Plan denied your request. The Plan says the enrollee 
must receive care from a network 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 surgical pathology provided on September 14, 2022, by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the brain 
(78608). 
 
You asked the Plan to pre-approve a PET scan of the brain. You say that the service is medically necessary. 
The Plan denied your request. The Plan says The records do not support that the enrollee meets diagnostic 
criteria for both AD and FTD. The medical records do not indicate concern for FTD so does not support 
evaluation with PET/CT. 
 
The Plan follows Medicare rules. The Plan follows Medicare rules. Medicare rules say that an FDG PET scan 
is only covered when there is a need to separate a differential diagnosis of frontotemporal dementia and 
Alzheimers disease. 
 
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 PET scan of the brain. Our reviewer 
says that the requested service is not medically necessary. Our physician reviewer found the records provided 
did not suggest that the enrollee was being evaluated for both AD and FTD. Rather, the notes only suggested 
cognitive impairments and a family history of AD. Given that the enrollee does not meet diagnostic criteria for 
AD and FTD at the same time, the request would not meet the initial requirement set forward by the NCD.  
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 PET scan of the brain have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a positron emission tomography (PET) scan of the brain (78608).