Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six (6) additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that continued physical therapy is medically 
necessary for this enrollee The Plan denied your request. The Plan says they have agreed to approve five of the 
requested eleven additional visits to intensely focus on finalizing the home exercise program (HEP) and to continue educating and reinforcing the importance of continued adherence to this HEP post discharge. The 
additional visits requested are not medically reasonable and necessary. 
 
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 additional PT 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 the additional therapy requested generally is not accepted as 
specific and effective therapy for the enrollees condition beyond what was approved by the health plan. The 
enrollee has had prior therapy and the documentation does not reveal that the enrollee requires the unique skills 
of a professional therapist to safely and effectively provide treatment, or that the services can only be safely 
and effectively performed by a therapist or by or under the supervision of a therapist. The enrollee has been 
approved ample therapy to transition to a home exercise program. The requested services are not part of a 
maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required 
to establish, design and/or deliver a program to maintain the enrollees current condition or to prevent or slow 
further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve six (6) additional physical therapy (PT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing identified with code 80307 and the rhythm 
Electrocardiogram (ECG) identified with code 93040 provided on October 14, 2021. 
 You asked the Plan to pay for the drug testing and the rhythm ECG. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the 
documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also state that providers may bill 
services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.   
 
In this case, the CPT Code Manual definition of code 80307 is drug test(s), presumptive, any number of drug 
classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay 
[eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry 
either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, 
MALDI, TOF) includes sample validation when performed, per date of service. The CPT Code Manual 
definition of code 93040 is rhythm ECG, 1-3 leads; with interpretation and report. 
 
We find that CPT codes 80307 and 93040 are not supported in the medical record. Specifically, the 
documentation submitted did not include a lab result of Drug test(s), presumptive, any number of drug classes, 
any number of devices or procedures; by instrument chemistry analyzers; therefore, code 80307 cannot be 
verified. Code 93040 is included in code 95921 (that was already approved/paid by the plan) and is therefore, 
not separately payable. In addition, the documents received do not support that the procedure or service was 
distinct or independent from other services performed; therefore, the use of the 59 modifier is not supported. 
Based on this information, we decided that Medicare rules for coverage of the drug testing and the rhythm ECG 
have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing identified with 
code 80307 and the rhythm Electrocardiogram (ECG) identified with code 93040 provided on October 14, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for emergency room (ER) services provided 
from June 3, 2021 to June 4, 2021. 
 
You asked the Plan to waive the deductible for the ER services. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the deductible 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. Your 
contract with the Plan says that there is a $1000 deductible which applies to Emergency care.  
 
 
  The item or service you asked the Plan to waive the deductible for falls within the benefit category Emergency 
care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 deductible 
which applies to Emergency care. This cost sharing is a contractual obligation that had not been met at the time 
the ER services was received on June 3, 2021 to June 4, 2021. Therefore, we decided that the Plan does not 
have to waive the deductible for emergency room (ER) services provided from June 3, 2021 to June 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two core buildups, including any pins when required 
(D2950 x2) and bridge (including pontic (D6245) and two retainer crowns (D6740 x2)) provided on March 1, 2022. 
 
  You asked the Plan to pay for the core buildups and bridge. You say that your plan covers 50% for a crown, 
and you do not understand why your claim should be denied just because the crowns are joined together. You 
also say that you feel the Plan's denial is unreasonable given they would have reimbursed the 50% if the 3 
crowns had not been joined together. The Plan denied your request. The Plan says these services are not 
covered expenses under your dental plan. The Plan also says that when you contacted the Plan on February 16, 
2022 you were advised that bridges are not a covered benefit under your plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the two 
core buildups, including any pins when required (D2950 x2) and bridge (including pontic (D6245) and two 
retainer crowns (D6740 x2)) provided on March 1, 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 January 19, 2022. 
 
You asked the Plan to pay for a limited oral evaluation. You say that you were told you were allowed two 
exams a year. The Plan denied your request. The Plan says D0140 is not a covered dental benefit. 
 
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 limited 
oral evaluation (D0140) provided by a participating provider on January 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 13, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that on January 13, 2022, blood was drawn in the 
office of your oncologist, and you found out that the chemical work is handled through an out-of-network 
provider. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and 
the services were not referred by a network provider or rendered in an in-network facility. The Plan also says 
that they have also determined that these services are not urgent or emergent, nor were they approved in 
advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for laboratory services provided on January 13, 2022, 
by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS) trial. 
 
You asked the Plan to pre-approve a spinal cord stimulator (SCS) trial. You say that these services are 
medically necessary. The Plan denied your request. The Plan says that there is no documentation the 
psychological screening has been performed at the time. 
 
The Plan must follow Medicare rules. Medicare rules say that patients must undergo appropriate psychological 
screening prior to implantation of spinal cord stimulators.  
 
We looked at the file and Medicare rules. The file does not indicate you have undergone appropriate 
psychological screening. Based on this information, we decided that Medicare rules for coverage of a spinal 
cord stimulator (SCS) trial have not been met. Therefore, we decided that the Plan does not have to pre-
approve a spinal cord stimulator (SCS) trial.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extractions (D7140 and D7120) and anesthesia (D9230), 
provided by a participating provider on November 29, 2021. 
 
You asked the Plan to pay for extractions and anesthesia. You say that you have not used these services before. 
You say that you think this may have been denied in error. The Plan denied your request. The Plan says the 
maximum benefit allowance amount has already been met and exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum 
dental allowance amount of $1,500. 
 
We looked at the file and Medicare rules. Evidence was provided to show that the dental maximum allowance 
amount was met and exhausted prior to the rendered services provided on November 29, 2021. Based on this 
information, we decided that the Plan's rules for coverage of extractions and anesthesia have not been met. 
Therefore, we decided that the Plan does not have to pay for extractions (D7140 and D7120) and anesthesia 
(D9230), provided by a participating provider on November 29, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary as the enrollee 
wants to regain strength, mobility, and self-care skills. The Plan denied your request. The Plan says the enrollee 
does not meet criteria for SNF care and can be treated in a lower level of care such as at home with home 
health services, in residential care or at home with a close follow-up from their doctor. 
 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. 
 
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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that the enrollee does not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The 
enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on 
an inpatient basis in a skilled nursing facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Nursing Facility Services provided on December 15, 2021 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for Nursing Facility Services. You say that you would like to request reconsideration 
for payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 Nursing Facility Services provided on December 
15, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement grafts (D4263 and D4264), and a 
guided tissue regeneration (D4266), provided by a participating provider. 
 
You asked the Plan to pre-approve bone replacement grafts and a guided tissue regeneration. You say that you 
need these services done because it is conjunction with another procedure you need. The Plan denied your 
request. The Plan says the requested dental services 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 pre-approve bone 
replacement grafts (D4263 and D4264), and a guided tissue regeneration (D4266), provided by a participating 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wellness services provided on November 22, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for wellness services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 wellness services provided on November 22, 2021 
by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) of the brain (70551) provided on January 6, 2022.

You asked the Plan to waive the copayment for the MRI. You say that the services should be covered as you disagree with the charges. 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 $200 copayment for Outpatient hospital services. 

You have been asked to pay a $190.65 copayment for an MRI, which is less than the standard $200. MRI's fall within the Outpatient hospital 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 magnetic resonance imaging (MRI) of the brain (70551) provided on January 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on February 15, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says services provided by an out-of-network provider are 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 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 dental services provided on February 15, 2022, by 
an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation services (A0427) 
provided on November 26, 2021, and November 27, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation services. You say that the 
services should be covered as you disagree with the charges. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $225 copayment for Ambulance services.  
 
 
  The enrollee has been asked to pay a $450 copayment for two ambulance transportation trips ($225 x 2 = 
$450). This means that the enrollee has been asked to pay the correct amount based on the contract with the 
Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for ambulance transportation 
services (A0427) provided on November 26, 2021, and November 27, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiac risk assessment genetic screening testing (81479) provided January 5, 2021.
You asked the Plan to pay for the genetic screening. You say that you believe that the treatment sought is medically necessary to treat the enrollee based on the enrollee's medical condition. The Plan denied your request. The Plan says the services do not meet coverage requirements.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. Genetic cardiovascular screening testing does not meet the definition of cardiovascular disease screening and is excluded from Medicare coverage as outlined by 42 CFR 410.17. The test at issue in this appeal, the genetic screening, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the cardiac risk assessment genetic screening testing (81479) provided January 5, 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 IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF care is not medically necessary and your ongoing skilled therapy and nursing 
needs can be met at a lower level of care such as in a skilled nursing facility or at home with home health 
services. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that your rehabilitation needs can be provided in an alternate and low intensity setting 
such as in a skilled nursing facility. 
 
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.