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

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service September 1, 
2022. 
 
You asked the Plan to pay for procedure code 76642. You say that the enrollee had multiple exams on this date. 
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 76642 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 of 
procedure code 76642 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76642 billed for date of service September 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the re-cement crown (D2920) and the extraction 
(D7140) for tooth #11, #23, #25, and #26 provided on June 16, 2022, and July 19, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you would like the Plan to pay for the 
dental services The Plan denied your request. The Plan says you are responsible for any charged amount above 
the Plans cost-sharing amount when your services are received from an out-of-network provider. 
 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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for the re-cement crown (D2920) and the 
extraction (D7140) for tooth #11, #23, #25, and #26 provided on June 16, 2022, and July 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient stay provided from July 28, 2022, to July 31, 
2022. 
 
You asked the Plan to pay for the inpatient stay. You say that you would like this case to be reviewed for 
proper reimbursement. The Plan denied your request. The Plan says there were no seizures or complications 
from COVID-19. The Plan also says the notes indicate that the enrollee was ready for transfer to Acute 
Rehabilitation. 
 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 pay for the inpatient stay. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found during these dates of service the enrollee did not require inpatient level of care services. Our 
reviewer found that the enrollee did not need to remain in the inpatient hospital beyond July 28, 2022. 
 
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 inpatient stay have not been met. Therefore, we decided that the Plan does 
not have to pay for the inpatient stay provided from July 28, 2022, to July 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete maxillary denture (D5110) and a mandibular 
partial denture (D5214) provided by an out-of-network provider on August 19, 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 31, 2022. Therefore, 
we decided that the Plan does not have to pay for a complete maxillary denture (D5110) and a mandibular 
partial denture (D5214) provided by an out-of-network provider on August 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a 2D oral/facial photographic image obtained intra-orally or 
extra-orally (D0350) provided on August 17, 2022. 
 
You asked the Plan to pay for a 2D oral/facial photographic image obtained intra-orally or extra-orally 
(D0350). You say that your contract states that dental service of an examination and cleaning is included. The 
Plan denied your request. The Plan says this service is not covered under the member's contract under any 
normal circumstances 
 
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 2D 
oral/facial photographic image obtained intra-orally or extra-orally (D0350) provided on August 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an oral evaluation (D0120) provided on August 11, 2022.

You asked the Plan to pay for the dental service. You say that the provider needed to do an exam so they could
make dentures. 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 Plan's 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 the date of service of July 13, 2022.
Therefore, we decided that the Plan does not have to pay for an oral evaluation (D0120) provided on August
11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified preventative procedure (D1999) and the 
delivery of antimicrobial agents (D4381) for tooth #14 and #15 provided on August 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that you do not want to be charged for any of the 
services that were done on the date of service. The Plan denied your request. The Plan says the denial of 
payment for these services is correct, because the unspecified preventative procedure and the delivery of 
antimicrobial agents are not covered by the 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 an 
unspecified preventative procedure (D1999) and the delivery of antimicrobial agents (D4381) for tooth #14 and 
#15 provided on August 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prescription/fitting contact lenses and the fundus 
photography provided on September 7, 2022.  
You asked the Plan to pay for the fundus photography. You say that these services should be covered under 
your insurance. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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 does not cover fundus photography as a part of the routine eye exam. 
 
We looked at the file and the Plan's rules. Specifically, the fundus photography is not a covered supplemental 
benefit. Based on this information, we decided that the Plan's rules for coverage of the fundus photography 
have not been met. Therefore, we decided that the Plan does not have to pay for the prescription/fitting contact 
lenses and the fundus photography provided on September 7, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve bioimpedance spectroscopy services. 
 
You asked the Plan to pre-approve bioimpedance spectroscopy services. You say that the enrollee was 
diagnosed with breast cancer and underwent left breast biopsy. You say that the enrollee was high risk of 
developing lymphedema as a result of that treatment and the use of ImpediMEd's L-Dex technology was 
medically necessary to monitor the enrollee for lymphedema. The Plan denied your request. The Plan says that 
a review of the current medical literature does not consider this service to be standard medical treatment for the 
diagnosis of lymphedema. The Plan says that the requested testing is less accurate than other testing modalities 
of lymphedema. The Plan says that additional research and development is needed before the requested method 
can be accepted for routine clinical use. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 bioimpedance spectroscopy services. 
Our reviewer says that bioimpedance spectroscopy services are considered medically reasonable and necessary 
in this case. Our physician reviewer found bioimpedance spectroscopy for breast cancer related lymphedema 
assessment has become a standard of care for prevention and treatment. Clinical measurements are obtained 
initially to establish a baseline before breast cancer treatments and afterward at intervals to track changes 
during treatment. Alternatively, changes in arm circumference or volume relative to the contralateral normal 
limb can be performed. Given that the highest risk of developing lymphedema is within the first three years of 
treatment and that early intervention can limit progression of disease, high-risk patients should be followed 
closely in this period. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bioimpedance spectroscopy services have been met. Therefore, we decided that 
the Plan has to pre-approve bioimpedance spectroscopy services.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 28, 2022. 
 
You asked the Plan to pay for the lab services. You say that the testing was medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 28, 2022.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for emergency department visit for the evaluation and management of a 
patient (Current Procedural Terminology (CPT) code 99285) provided on May 3, 2021. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says that the service is not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not substantiate their denial of the code not being able to be billed 
with this provider or their specialty. Therefore, we decided that the Plan has to pay for emergency department 
visit for the evaluation and management of a patient (Current Procedural Terminology (CPT) code 99285) 
provided on May 3, 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF care. The Plan denied your 
request. The Plan says IRF care 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 that the complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IR 
 
 
 
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: 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 the services requested are medically necessary. The 
Plan denied your request. The Plan says the criteria for admission to SNF have not been met. 
 
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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the member's physical function is at or near his baseline and he can receive services 
at a lower level of care.  Admission to a SNF for inpatient skilled rehab services is 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 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services provided from July 27, 2021, to  
August 4, 2021. 
 
You asked the Plan to pay for the hospital services. The Plan denied your request. The Plan says in accordance 
with Medicare guidelines, the provider needs to bill Original Medicare, using the proper modifiers, for services 
rendered from July 27, 2021 through July 31, 2021. Per the regulations above, the members services rendered 
from July 27, 2021 through July 31, 2021would be covered under Original Medicare as it is responsible for 
coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. It is the providers responsibility to verify the members coverage before rendering services and to 
know proper billing procedures for a Medicare Advantage member on hospice. The claim was correctly denied 
because the providers claim included billed dates of service July 27, 2021 through July 31, 2021 that were part of the 
Hospice month within the date span July 27, 2021 through August 04, 2021. When a provider has a date range that 
includes dates of service that were part of the Hospice month and dates of service that were not part of the Hospice 
month, they should only submit a claim to the Plan for the dates of service that we are liable to pay, which were dates of 
service August 01, 2021 through August 04, 2021. Dates of service July 27, 2021 through July 31, 2021 were part 
of the Hospice month fee-for-service period and should be billed directly to Medicare FFS. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on July 27, 2021. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for hospital services provided 
from July 27, 2021, to August 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for opioid treatment services (G2067) provided on September 
12, 2022. 
 
You asked the Plan to pay for the opioid treatment services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the documentation provided does not support the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the opioid treatment services have 
been met. Documentation was not provided to show that the individual provider is Substance Abuse and Mental Health Services Administration certified to provide this service. Therefore, we decided that the Plan 
does not have to pay for opioid treatment services (G2067) provided on September 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77063 and 77067 billed for date of service 
August 29, 2022. 
 
You asked the Plan to pay for procedure code 77063 and 77067. You say that the records support separate 
services were provided. 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 77063 and 77067 is 1. The MAI value for each of these codes is 2. You 
billed 2 units of each code, exceeding the MUE. Based on this information, we decided that Medicare rules for 
coverage of procedure code 77063 and 77067 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 77063 and 77067 billed for date of service August 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomographic angiography (CTA) of the 
abdominal aorta and bilateral iliofemoral lower extremity runoff. 
 
You asked the Plan to pre-approve the CTA. You say that it is medically necessary for the enrollee to get a 
CTA done. The Plan denied your request. The Plan says the records do not show that the planned arterial 
duplex study was done; therefore, the authorization for a CTA is denied. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CTA. Our reviewer says that the 
documentation does not support the medical necessity of the CTA. Our physician reviewer found that the 
consulting vascular surgeon recommended a follow-up duplex ultrasound, not a CTA. A CTA has already been 
performed so the anatomic details provided by a CTA are known. Follow up for small pseudoaneurysms are 
typically obtained with ultrasound as it avoids the risks of contrast dye and radiation. There is no consideration 
for a CTA indicated in the medical records provided. Agree with the Plan's determination unless additional 
medical records supporting the CTA are submitted. 
 
  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 CTA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a computed tomographic angiography (CTA) of the abdominal aorta and bilateral iliofemoral 
lower extremity runoff.