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

 
We decided that the Plan does not have to pay for lab services provided on April 30, 2021. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment of this claim. 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 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 April 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services you received from March 4, 2021, to 
November 22, 2021. 
 
You asked the Plan to pay for the chiropractic services. You say that these services should be paid because the 
same services were covered before with this provider using the same coding. The Plan denied your request. The 
Plan says for these dates of service, your chiropractor billed these services with the GA modifier, which 
indicates that these services were for maintenance therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.   
Your chiropractic provider billed these services as maintenance therapy, which is not covered by either 
Medicare or your Plan. Based on this information, we decided that Medicare rules for coverage of the 
chiropractic services have not been met. Therefore, we decided that the Plan does not have to pay for 
chiropractic services you received from March 4, 2021, to November 22, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided to the enrollee on 
December 8, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the codes were denied because they did not include the appropriate primary, first-listed or 
principal diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 90791, 96136, 96137 are not supported in the medical record. Specifically, the denied 
codes were billed with a secondary diagnosis code in the place of the primary, first-listed diagnosis code. Based 
on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, 
we decided that the Plan does not have to pay for outpatient mental health services provided to the enrollee on 
December 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on October 20, 2021. 
  You asked the Plan to pay for physical therapy services. You say that plans must pay non-contract providers at 
the preferred provider rate when services are not available from preferred providers in the service area. You say 
that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your 
request. The Plan says the code is not appropriate for the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that therapy services billed as services incident to a 
physician/non-physician practitioners service must meet all incident requirements. Medicare rules also say that 
the services of PTA shall not be billed as services incident to a physician/non-physician practitioner's (NPP) 
service, because they do not meet the qualifications of a therapist. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of physical therapy services have not been met. Specifically, the records do not indicate if the 
rendering provider was a physical therapist or a PTA. A nurse practitioner is not able to bill for the services of 
an PTA because the nurse practitioner is not a therapist. There is no evidence that the nurse practitioner was on 
the premises to be able to bill for OT services. Additionally, the record does not include the rendering providers 
credentials, so we are unable to verify the billed services. Therefore, we decided that the Plan does not have to 
pay for physical therapy services provided on October 20, 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 had hip surgery and does not want to go 
to a nursing home. You say that the enrollee is still in the hospital but needs to be discharged. The Plan denied 
your request. The Plan says the enrollees ongoing skilled therapy and nursing needs can be provided at a lower 
level of care. 
 
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 there are no complex nursing or rehabilitation needs. While the enrollee has a 
need for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study. 
 
You asked the Plan to pre-approve the study. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show signs or symptoms of obstructive sleep apnea. 
 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 study. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the appeal note has complaints of difficulty sleeping. The medical record consists of a visit on 4/15/22. 
That visit does not include a sleep history, and does not indicate a need for a sleep study. There is no 
quantitative assessment of daytime sleepiness.  There is no detailed upper airway examination or neck 
circumference. 
 
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 study have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a sleep study.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77080 billed for date of service September 
13, 2021. 
 
You asked the Plan to pay for procedure code 77080. You did not provide a specific argument with your appeal 
request. The Plan denied your request. The Plan says it cannot determine if these services were medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. In this case, the Plan has repeatedly requested medical records from you to support 
the medical necessity of this service and to determine what doctor ordered these services for the patient.  To 
date, you have not responded to these requests.  Without any medical records, the medical necessity of this 
service cannot be substantiated. Based on this information, we decided that Medicare rules for coverage of procedure code 77080 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 77080 billed for date of service September 13, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided to the enrollee on 
December 10, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says a secondary only diagnosis cannot be used as the primary, first-listed or principal diagnosis for 
any procedure or service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 96132 and 96133 is not supported in the medical record. Specifically, a secondary only 
diagnosis code was used for a primary diagnosis code in this case. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for outpatient mental health services provided to the enrollee on December 10, 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. The Plan denied your request. The Plan says your medical and 
therapy needs can be met at the current acute care hospital. 
 
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 there are no complex nursing or rehabilitation needs. While you have a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that denial of LTACH level of care will 
seriously jeopardize the enrollee's health and ability to regain function. You say that a skilled nursing facility 
will not provide adequate care for his current health disposition, and he is clinically stable for discharge to an 
LTACH. The Plan denied your request. The Plan says the records do not show that it is medically necessary for 
the enrollee to be in an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the medical record does not indicate that the enrollee requires services that he is 
not currently receiving that would be available at the LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says an intensive rehabilitation program 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 you have debility from acute illness, but do not meet the coverage criteria for this 
admission. You are medically stable, with no acute problems. There is no medical complexity. You do not need 
close physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. No rehab nursing needs identified or documented in the 
record. At the current functional level, you do not need three hours a day, five days a week of IRF therapies 
with interdisciplinary management. Needs can be met in a lower intensity setting, such as a skilled nursing 
facility (SNF). 
 
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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pay for the admission. You say that this is medically necessary. The Plan denied your 
request. The Plan says all of the needed services are offered at the inpatient rehabilitation facility (IRF). 
 
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 pay for the admission. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found this is 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 the admission have not been met. Therefore, we decided that the Plan does not 
have to pay for admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral hygiene instruction (code D1330) and the scaling 
and root planing (code D4341) you received on November 30, 2021. 
 
You asked the Plan to pay for the oral hygiene instruction and the scaling and root planing. You say that this 
dentist refused to provide complete service to you. The Plan denied your request. The Plan says your benefits 
do not cover oral hygiene instruction, and you have exhausted your benefit for root scaling and planing. 
 
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. Your contract lists the specific 
dental services that are covered under your Plan.  Oral hygiene instruction is not listed as a covered benefit.  In 
addition, your contract says that you are only covered for scaling and root planing once every three years.  Records show that you received covered scaling and root planing on December 15, 2020, so you were not 
eligible for coverage of this service on November 30, 2021. Therefore, we decided that the Plan does not have 
to pay for the oral hygiene instruction (code D1330) and the scaling and root planing (code D4341) you 
received on November 30, 2021.  
 
Your complaint about the dentist refusing to complete your treatment is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary visit provided on December 29, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary visit. You say that the provider relied on the facility staff to 
verify and obtain authorization from the enrollee's insurance company. You say the service was medically 
necessary. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
 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 domiciliary visit at issue in this appeal. The Plan did not pre-approve 
the domiciliary visit. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the domiciliary visit provided on December 29, 2021, by an out-
of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 43659 billed for date of service November 
15, 2021. 
 
You asked the Plan to pay for procedure code 43659. You say that this code should be paid. The Plan denied 
your request. The Plan says the record does not support this service. 
 
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 43659 is unlisted laparoscopy procedure, stomach. 
 
We asked our coder 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 procedure code 43659. Our reviewer says that code 43659 is 
not supported in the medical record. Our reviewer found you are reporting an unlisted procedure for gastropexy 
performed during same session of a Paraesophageal hiatal hernia.  In this case, when a major esophagogastric 
procedure is performed, gastropexy would be considered an included component of the major esophagogastric procedure.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 43659 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 43659 billed for date of service November 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary visit provided on December 27, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary visit. You say that the provider relied on the facility staff to 
verify and obtain authorization from the enrollee's insurance company. The Plan denied your request. The Plan 
says no prior authorization was obtained. 
 
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 did not pre-approve the 
domiciliary visit. We found no exception that would require the Plan to pay for the domiciliary visit. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the domiciliary visit provided on December 27, 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 CT scan provided on December 16, 2021 
and December 29, 2021. 
 
You asked the Plan to waive the copayment for CT scans. You say that you should not be charged a copayment 
for each of the CT scans. The Plan denied your request. The Plan says copayment is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $250 
copayment for other outpatient diagnostic test computed tomography (CT), magnetic resonance angiogram 
(MRA), magnetic resonance imaging (MRI) and positron emission tomography (PET).   
You have been asked to pay $416.418 for the CT scans.  
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
December 16, 2021 CT scan $4,577.39 $250 $250 
December 29, 2021 CT scan $1,988.82 $250 $166.18 
Total    $416.18 
 
CT scan falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for computed tomography (CT) scans provided on December 
16, 2021 and December 29, 2021.