Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network services provided to the enrollee on October 
21, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The 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 out of network services provided to the enrollee on 
October 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the urology office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the urology office visit. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the provider is out-of-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the urology office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgery services provided on August 14, 2021.  
You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says the billed codes cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
In this case, the CPT Code Manual definition of code 37249 is transluminal balloon angioplasty (except 
dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation 
necessary to perform the angioplasty within the same vein; each additional vein (List separately in addition to 
code for primary procedure). We find that code 37249 is not supported in the medical records. The services on 
an additional vein were not described in the medical records.  
 
In this case, the CPT Code Manual definition of code 75820 is venography, extremity, unilateral, radiological 
supervision and interpretation. We find that the code was billed with a -59 modifier. The medical records 
provided do not show that the service billed with the -59 modifier is a distinct procedural service. 
 
In this case, the CPT Code Manual definition of code 99153 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List 
separately in addition to code for primary service). We find that this is a code that describes the technical 
component. There is an associated code that describes the professional component of the diagnostic test. Based 
on this information, we decided that Medicare rules for coverage of the services provided have not been met. 
Therefore, we decided that the Plan does not have to pay for the surgery services provided on August 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified mass spectrometry provided on August 4, 2021. 
 
You asked the Plan to pay for the unspecified mass spectrometry. You say that these services should be paid. 
The Plan denied your request. The Plan says payment is approved for G0480; however, separately payment 
cannot be made for specimen validity testing. 
 
The Plan must follow Medicare rules. Medicare rules say that no separate payment can be made for specimen 
validity testing for drug testing.  
In this case, the mass spectrometry is reported for specimen validity testing which is not allowed per Medicare 
rules. Therefore, we decided that the Plan does not have to pay for the unspecified mass spectrometry provided 
on August 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the onlay (D2544), provided on August 6, 2021. 
 
You asked the Plan to pay for the onlay. You say that the service should be covered. The Plan denied your 
request. The Plan says you obtained this service out-of-network. 
 
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 onlay 
(D2544), provided on August 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical nutrition therapy (97803) provided on 
January 1, 2021. 
 
You asked the Plan to pre-approve the medical nutrition therapy. You say that you would like reconsideration 
because these services are medically necessary and have helped to treat your condition. The Plan denied your 
request. The Plan says you have exhausted your wellness benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes. The Plan offers an additional benefit in excess of Medicare 
coverage. The Plan rules apply in this case. 
 
We looked at your request, the file and rules. Based on this information we have determined that the criteria for 
coverage have not been met. Specifically, the contract with the Plan states that up to $150 is covered annually 
for your wellness benefit. The record shows that this benefit has been exhausted. Of note, this service does not 
fall under the Plan's weight management benefit. Therefore, we decided that the Plan does not have to pre-approve the medical nutrition therapy (97803) 
provided on January 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs inpatient rehabilitation because 
they live alone, and inpatient rehabilitation will help the enrollee to carry out their daily living activities and 
remain safe at home. The Plan denied your request. The Plan says the stay is not medically necessary based on 
IRF criteria. The Plan states the enrollee could receive care in another setting and the Plan could review 
alternate settings if requested, such as skilled nursing facility, or home with home health and home physical 
therapy. 
 
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 based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollees medical conditions appear to be stable on outpatient medications 
with no issues that require a physicians evaluation three (3) or more times per week. The enrollee does require 
physical therapy and occupational therapy services, but the medical records provided do not clarify why the 
enrollee requires an intensive inpatient rehabilitation therapy program. Provided medical records do not explain 
why the intensive inpatient rehabilitation therapy program is necessary and why therapy at a lower level of care 
such as in a skilled nursing facility (SNF) is not appropriate for the enrollee. There is concern that the enrollee 
will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in 
an IRF given their reported level of pain and decreased endurance. Care at the SNF level appears to be 
appropriate in this case. 
 
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 IRF admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the physical therapy. You say that this facility has better equipment, and 
you have a good relationship with the therapy team. The Plan denied your request. The Plan says the provider 
is out-of-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the total knee replacement (CPT code 27447). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
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 service. Our physician reviewer 
found the medical records provided do not meet the requirements listed in the LCD for Medicare coverage. The 
enrollee had several cortisone injections over the years, but they have not proven to be helpful. The enrollee 
has difficulties with getting out of a seated position. Exam reveals left knee motion of 0-120. There is 
significant crepitus within the patellofemoral joint. However, detailed documentation is not evident regarding 
trial and failure of recent, reasonable, and comprehensive less invasive conservative care measures.  The enrollee was not seen for two (2) years and no indication of any conservative measures having been trialed 
during this time. Additionally, there was no provided diagnostic imaging provided for review to corroborate 
advanced arthritis in the left knee that could benefit from the requested procedure. The documentation does not 
indicate a failure of previous osteotomy, distal femur fracture, malignancy, previous unicompartmental knee 
replacement, avascular necrosis, or proximal tibia fracture. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
medical records provided do not meet the requirements listed in the LCD for Medicare coverage. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the total knee replacement (CPT code 27447).
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. The Plan denied your request. The Plan says the necessary care can be provided at a lower level of care.
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (97162, 97110, 97116, 97140, 97530, 
97112) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve physical therapy. You say that you have a lot of difficulty with large crowds 
and going to new places. The Plan denied your request. The Plan says you must get your care from network 
providers, and usually, the Plan will not cover care from a provider who does not work with the Plan. The Plan 
also says that there are in-network physical therapy facilities that they do cover that can offer the same care. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve physical therapy (97162, 97110, 97116, 97140, 97530, 97112) to be provided by an out-of-network (OON) 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network 
(OON) provider on November 5, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered by the out-of-network (OON) provider on 
November 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network services provided to the enrollee on September 29, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The 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 out of network services provided to the enrollee on September 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 panel provided on June 15, 2021.
You asked the Plan to pay for the Guardant360 panel. You say that it is felt that the POS code rules being cited only apply to testing paid on the Physician Fee Schedule (PFS). The Plan denied your request. The Plan says the reported POS code does not match where the sample was taken.
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. The documentation does not indicate this sample was taken by the lab directly. As such, the use of POS code 81 is not supported. Based on this information, we decided that Medicare rules for coverage of the Guardant360 panel have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 panel provided on June 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the filling (D2332) provided on November 6, 2021. 
 
You asked the Plan to pay for the dental service. You say that you were assured by a plan representative prior 
to the date of service that your fillings would be fully covered as long as the dentist used one of the codes for 
fillings that are listed. You also say that the dentist used one of those codes. The Plan denied your request. The 
Plan says filling is not listed as 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the filling is not among those covered 
under this benefit. Additionally, the file shows that you were not given incorrect information by the pan 
representative. Therefore, we decided that the Plan does not have to pay for the filling (D2332) provided on 
November 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve upper limb myoelectric prosthesis terminal device with additions.
You asked the Plan to pre-approve the myoelectric prosthesis. You say that the enrollee has exceeded the functional capability of her current prosthesis. The Plan denied your request. The Plan says the current prosthesis is 11 months old and under warranty. Medicare does not cover duplicate services.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.
The file shows that the enrollee has an upper limb myoelectric prosthesis terminal device with additions. The current prosthesis was provided 01/28/2021 and is under warranty Therefore, we decided that the Plan does not have to pre-approve upper limb myoelectric prosthesis terminal device with additions.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), 
and re-cement or re-bond crown (D2920) provided on August 30, 2021, and October 7, 2021 by a Medicare opt 
out provider. 
 
You asked the Plan to pay for the periodic oral evaluation, prophylaxis, and re-cement or re-bond crown. You 
say that you were not aware that the treating provider had opted out of Medicare. The Plan denied your request. 
The Plan says you received these services from a provider who chose not to receive Medicare funds. 
 
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 
covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the 
Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), and re-cement or re-
bond crown (D2920) provided on August 30, 2021, and October 7, 2021 by a Medicare opt out provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (x-ray) 
(D0220), provided on October 12, 2021. 
 
You asked the Plan to pay for the dental x-ray. You say that the service should be covered. The Plan denied 
your request. The Plan says this 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 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. Specifically, this service is not listed in the Plan's benefit chart. This 
means the service is not covered. Therefore, we decided that the Plan does not have to pay for the intraoral - 
periapical first radiographic image (x-ray) (D0220), provided on October 12, 2021.