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

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from June 3, 
2022, to July 2, 2022. 
 You asked the Plan to pay for SNF care. You say that you would like to request reconsideration of the denied 
claim. The Plan denied your request. The Plan says custodial care is not a covered service. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. 
Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from 
June 3, 2022, to July 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyewear (codes V2020 and V2200) purchased on August 
31, 2022. 
 
You asked the Plan to pay for the eyewear. You say that you did not know that the plan changed. You also say 
that you have always been able to get your frames every year. The Plan denied your request. The Plan says the 
service is a covered benefit, but you have exceeded limits set in the subscriber agreement. 
 
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 1 pair of standard lenses and frames every 2 years. 
 
We looked at the file and the Plan's rules. Specifically, the record shows that the Plan paid for eyeglasses that 
were purchased on March 31, 2021, and your eyewear benefit has been exhausted. 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 (codes V2020 and V2200) purchased on August 31, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 4, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 4, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 8, 2022, to 
May 3, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from April 8, 2022, to May 3, 
2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ER visit provided on June 09, 2022. 
 
You asked the Plan to waive the copayment for ER visit. You say that you left without being treated so you 
shouldnt have to pay. 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 $90 
copayment for Emergency care. 
 
You have been asked to pay a $90 copayment for ER visit. This item/service falls within the Emergency 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 ER visit provided on June 09, 
2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service April 7, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 99100 is considered bundled and not separately 
payable. 
 
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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service April 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient hospital services provided to the enrollee 
from November 20, 2022, to November 22, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The 
Plan denied your request. The Plan says the information received does not support an acute inpatient stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that this hospitalization does not qualify for inpatient payment under the two-
midnight rule. At the time of admission, it was not reasonable to expect that two midnights in the hospital 
would be required. The enrollee could have been placed on observation status fir further monitoring before 
deciding if two midnights of care would be necessary.  As is, the enrollee appears to have remained stable and 
eligible for discharge after only one midnight 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for acute inpatient hospital services provided to the enrollee from November 20, 
2022, to November 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions (D7140, D7210), alveoloplasty (D7310), a 
complete maxillary denture (D5110), and an immediate mandibular denture (D5140) provided on August 30, 
2022. 
 
You asked the Plan to pay for the dental services. You say that due to circumstances beyond your control your 
dental coverage was terminated. The Plan denied your request. The Plan says the requested services are not 
covered by your dental 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 
extractions (D7140, D7210), alveoloplasty (D7310), a complete maxillary denture (D5110), and an immediate 
mandibular denture (D5140) provided on August 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213 billed for date of service July 27, 
2022. 
 
You asked the Plan to pay for procedure code 99213. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 99213 is bundled into payment for code 11900. 
 
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 99213 
is a column II code to column I code 11900. While code 99213 was billed with modifier 25, there were no new 
conditions diagnosed or treated and no new prescriptions were provided to consider 99213 as a significant and 
separate evaluation and management service to bill with modifier 25. This means this claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99213 billed for 
date of service July 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated wheelchair/scooter 
 
You asked the Plan to pre-approve a power operated scooter. You say that you have had neuromuscular issues 
for over 25 years. You cannot sweep, vacuum, stand to dust or fold laundry. Everyday household chores now 
cause me worsening pain. The Plan denied your request. The Plan says the request for a power operated vehicle 
(commonly called a scooter) has not been approved as it was found not to be medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that you do not have a mobility deficit that impairs your participation in MRADLs, and your 
condition can be improved by a walker, cane or manual wheelchair. This means that Medicare rules for 
coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
power operated wheelchair/scooter
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on August 9, 2022. 
 
You asked the Plan to pay for the office visit. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services are not payable 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, the CPT Code Manual definition of code 99212 is office or other outpatient visit for the evaluation 
and management of an established patient, which requires a medically appropriate history and/or examination 
and straightforward medical decision making. When using time for code selection, 10-19 minutes of total time 
is spent on the date of the encounter. 
 
We find that CPT code 99212 is not supported in the medical record. Specifically, this evaluation and 
management service is included in the anesthesia package for the anesthesiologist. This means this code is 
bundled and cannot be separately paid as billed. Based on this information, we decided that Medicare rules for 
coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for the 
office visit provided on August 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman G3-R MIS fusion plate. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary, and the denial is 
unwarranted. The Plan denied your request. The Plan says experimental procedures are not covered. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the minuteman plate device is experimental in spine surgery. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Minuteman G3-R MIS fusion plate.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided December 15, 2021, to 
December 18, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that an admission was medically necessary 
for the enrollee. The Plan denied your request. The Plan says that these services were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the review indicates that the record did show that at the time of inpatient admission the 
admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided December 15, 2021, to December 18, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial inpatient psychiatric hospital admission and 
services. 
 
You asked the Plan to pre-approve these services. You say that a partial inpatient psychiatric hospital 
admission is medically necessary. The Plan denied your request. The Plan says you do not meet medical 
necessity criteria for coverage of a partial inpatient psychiatric admission. 
  
The Plan follows Medicare rules. Medicare rules say that the patient must require intensive, comprehensive, 
multifaceted treatment including 24 hours per day of medical supervision and coordination because of a mental 
disorder. 
 
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 these services. Our reviewer says that a 
partial inpatient psychiatric hospital admission is not medically necessary. Our physician reviewer found that 
you are requesting a preservice authorization for treatment in a partial hospitalization program. Based upon the 
review of the records provided, you are not showing any dangerousness to self or others and have not been 
exhibiting severe psychological or a psychiatric impairment requiring this level of care. You are not showing 
any perceptual disturbance, psychosis or aggressive behaviors. It does not appear medically necessary and 
reasonable to have psychiatric care provided at the partial hospitalization level of care rather than a lower level 
of care as you do not have any suicidal or homicidal thoughts or behavioral disturbance and your 
symptomatology could be treated at a lower level of care. The health plans denial of continued partial 
hospitalization treatment for the dates in question appears appropriate. You are not showing any severity of 
psychological or psychiatric illness. Based upon the review of the records provided, you do not meet the 
criteria for treatment at a partial hospitalization level of care and could be treated in a lesser restrictive setting.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a partial inpatient psychiatric hospital admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76882 billed for date of service June 18, 
2022. 
 
You asked the Plan to pay for procedure code 76882. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 76882 is bundled into payment for code 93985. 
 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 76882 
is a column II code to column I code 93985. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76882 billed for date of service June 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a participating 
provider on August 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service May 5, 2022. Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a participating 
provider on August 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the miscellaneous durable medical equipment (DME) supply 
or accessory, not otherwise specified coded A9999 provided on July 7, 2022. 
 
You asked the Plan to pay for the miscellaneous durable medical equipment (DME) supply or accessory, not 
otherwise specified. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan 
says the services billed are not supported. 
 
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 A9999 is Miscellaneous DME supply or accessory, not 
otherwise specified. 
 
 We find that CPT code A9999 is not supported in the medical record. Specifically, the items received were 
Solaris Ready Wraps for lymphedema. There is a more appropriate code to be billed for the items rendered. 
Based on this information, we decided that Medicare rules for coverage of the miscellaneous durable medical 
equipment (DME) supply or accessory, not otherwise specified have not been met. Therefore, we decided that 
the Plan does not have to pay for the miscellaneous durable medical equipment (DME) supply or accessory, not 
otherwise specified coded A9999 provided on July 7, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 9, 2022, to 
April 7, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from March 9, 2022, to April 
7, 2022.