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

 
We decided that the Plan does not have to pre-approve procedure code S2095. 
 
You asked the Plan to pre-approve procedure code S2095. You say that the services are necessary. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S2095 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S2095 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S2095 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve procedure code S2095.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you prefer to admit to acute rehabilitation because 
you were independent before the hospitalization and would like to return to being independent. The Plan denied 
your request. The Plan says based on Medicare guidelines, the 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 you were admitted for lumbar spinal surgery. Medical problems are stable. There 
are no complex nursing or rehabilitation needs. While you have a need for physical or occupational therapy, 
there is no documentation of a need for an intensive rehabilitation program. 
 
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 the IRF admission and services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the opioid treatment program (OTP) services provided from March 4, 
2022, to March 29, 2022. 
 
You asked the Plan to pay for the OTP services. You say that your organization is a certified OTP provider and 
this claim should be paid. The Plan denied your request. The Plan says that you did not bill with the appropriate 
type of bill on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that for facility-based claims (i.e., claims filed on for 
CMS-1450), providers must bill the appropriate Type of Bill (TOB) code in field 4 of the claim. For 
freestanding non-residential Opioid Treatment Programs, providers should bill with Type of Bill (TOB) code 
087x. Hospitals use TOB 013x, and Critical Access Hospitals use TOB 085x. Professional providers use form 
CMS-1500.  For professional claims, providers should enter a Place of Service code of 58 in box 24B to 
indicate a Non-residential Opioid Treatment Facility. 
 
In this case, the Plan's denial rationale is that you billed with an incorrect Type of Bill on the claim.  This is not 
correct.  The Plan's argument is not applicable here, because you submitted a professional claim, not an 
institutional one.  A type of bill code is only entered on institutional claims.  The instructions state that for 
professional claims (which this one was), an OTP program is properly indicated by entering a Place of Service 
code of 58, which you have done.  The Plan has provided no other argument for non-coverage of these 
services. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules 
for coverage of the OTP services have been met. Therefore, we decided that the Plan has to pay for the opioid 
treatment program (OTP) services provided from March 4, 2022, to March 29, 2022.  
 
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 an in-network mental health visit provided 
on April 11, 2022. 
 
You asked the Plan to waive the copayment for an in-network mental health visit. You say that you should not 
have to pay for this copayment. The Plan denied your request. The Plan says the copayment applied was 
correct. 
 
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 $20 
copayment for outpatient mental health care.  
 
You have been asked to pay a $20 copayment for an in-network mental health visit. An in-network mental 
health visit falls within the outpatient mental health 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 an in-network mental health visit provided on April 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with codes A6530 and 
A6533. 
 
You asked the Plan to pre-approve the compression stockings. You say that you are requesting a 
reconsideration of the Plan's denial. The Plan denied your request. The Plan says these items are not a covered 
benefit under your contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 and 
A6533 are noncovered because they do not meet the statutory definition of a surgical dressing.  
 
 Although these items may be appropriate, they do not fall into a covered benefit category and cannot be paid 
for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with codes A6530 and A6533.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a retroperitoneal ultrasound provided on 
March 1, 2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you feel you should not have to 
pay this bill. 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 $100 
copayment for diagnostic radiology services at an outpatient hospital.  
 
You have been asked to pay a $100 copayment for the ultrasound. The ultrasound falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for a retroperitoneal ultrasound provided on March 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric treatment. 
 
You asked the Plan to pre-approve inpatient psychiatric treatment. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric treatment. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based upon review 
of the records provided, this enrollee does not meet the criteria for August 14, 2022 forward as this enrollee was not shown to be a danger to herself or others. There were no delusions, auditory or visual hallucinations 
noted. She was cooperative/compliant with treatment while not showing any threats the safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric treatment have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient psychiatric treatment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for portable oxygen equipment provided on 
July 23, 2021. 
 
You asked the Plan to waive the coinsurance for the portable oxygen equipment. You say that you were not 
informed of any monthly costs for the equipment. The Plan denied your request. The Plan says the correct 
coinsurance was applied. 
 
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 20% coinsurance for durable medical equipment (DME) items, including oxygen equipment. 
 
Item Allowed Amount 20% Coinsurance 
Oxygen Concentrator $123.75 $24.75 
Portable Oxygen Machine $22.30 $4.46 
Total:  $29.21 
 
You have been asked to pay a total of $29.21, which is 20% of the allowed amount for the portable oxygen 
equipment. The portable oxygen equipment falls within the Durable Medical Equipment (DME) and Related 
Supplies benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for portable oxygen 
equipment provided on July 23, 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 the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided 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 for a crown-full cast high noble metal (D2790) provided on May 
17, 2022. 
 
You asked the Plan to pay for the crown. The Plan denied your request. The Plan says this procedure is not a 
benefit under your dental plan. 
 
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 a crown-
full cast high noble metal (D2790) provided on May 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 24, 2021, billed with 
codes 81206, 81292, and 81301. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
August 24, 2021, billed with codes 81206, 81292, and 81301.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inhalation of nitrous oxide/analgesia, anxiolysis (D9230) 
provided on January 20, 2022. 
 
You asked the Plan to pay for the nitrous oxide/analgesia. You say that this service was medically necessary. 
The Plan denied your request. The Plan says records sent do not show that there is a condition that makes this 
service necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the nitrous 
oxide/analgesia 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 pay for the nitrous oxide/analgesia. Our reviewer 
says that this service was not medically reasonable and necessary. Our physician reviewer found that a review 
of the documentation does not indicate that the enrollee had special needs or extreme anxiety to warrant the use 
of nitrous oxide anesthesia.  
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 the nitrous oxide/analgesia have not been met. Therefore, we decided that the 
Plan does not have to pay for the inhalation of nitrous oxide/analgesia, anxiolysis (D9230) provided on January 
20, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 14 physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that additional physical therapy is medically 
necessary. The Plan denied your request. The Plan says that the enrollees strength and movement has improved 
since starting therapy. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that 10 more sessions is quite reasonable to help the enrollee stabilize 
their condition and develop a home exercise program. The remaining 14 sessions are not medically 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 therapy visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 14 physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 25, 2021, billed with 
codes 81206, 81292, and 81301. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 25, 2021, billed with codes 81206, 81292, and 81301.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for portable oxygen equipment provided on 
January 23, 2022. 
 
You asked the Plan to waive the coinsurance for the portable oxygen equipment. You say that you were not 
informed of any monthly costs for the equipment. The Plan denied your request. The Plan says the correct 
coinsurance was applied. 
 
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 20% coinsurance for durable medical equipment (DME) items, including oxygen equipment.  
 
Item Allowed Amount 20% Coinsurance 
Portable Oxygen Machine $22.30 $4.46 
Oxygen Concentrator $123.75 $24.75 
Total:  $29.21 
 
You have been asked to pay a total of $29.21, which is 20% of the allowed amount for the portable oxygen 
equipment. The portable oxygen equipment falls within the Durable Medical Equipment (DME) and Related 
Supplies benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for portable oxygen 
equipment provided on January 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the bitewings - four radiographic 
images (D0274), periodic oral evaluation - established patient (D0120), prophylaxis - adult (D1110), and 
unspecified preventive procedure, by report (D1999) provided March 7, 2022. 
 
You asked the Plan to provide additional payment for the bitewing x-rays, periodic oral exam, dental cleaning 
and unspecified preventative procedure. You say that you were advised this provider was in-network. The Plan 
denied your request. The Plan says the claims has been reprocessed and the Plan has paid the in-network 
contracted rate. The unspecified preventative procedure is not 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 Plans coverage rules apply in this case. The Plan covers the bitewing 
x-rays, periodic oral exam and dental cleaning with a $0 copayment when provided in-network.  
We looked at the file and Medicare rules. The Plan provided documentation showing they have made an 
exception and re-processed the claims at the in-network rate. The Plan has covered the full allowed amount for 
the bitewing x-rays, periodic oral exam and dental cleaning. The out-of-network provider is not contracted with 
the Plan to charge the Plans rates. The provider may ask you to pay the amount charged above the Plans 
allowed amount. Though the Plan offers dental benefits in excess of Medicare coverage, the unspecified 
preventative procedure is not among those covered services.  Therefore, we decided that the Plan does not have 
to provide additional payment for the bitewings - four radiographic images (D0274), periodic oral evaluation - 
established patient (D0120), prophylaxis - adult (D1110), and unspecified preventive procedure, by report 
(D1999) provided March 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics. 
 
You asked the Plan to pay for foot orthotics. You say that orthotics helps with circulation, you have flat feet 
and need custom shoes because one foot is bigger than the other. By not having these inserts this will cause 
damage to your feet The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you had surgery on your left foot plantar fascia 
tendon to help with chronic plantar tendonitis, over time, this resulted in your left foot collapsing 3 toes curling 
causing hammer toes to compensate for the pain of your collapsed foot. The Plan denied your request. The Plan 
says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.