Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950), 
pontic (D6245), and retainer crowns (D6740) provided on March 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are on a limited income and cannot pay this 
bill. The Plan denied your request. The Plan says your benefit for the requested services 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 services was exhausted on date of service March 22, 2022. Therefore, we decided 
that the Plan does not have to pay for the core buildup, including any pins when required (D2950), pontic 
(D6245), and retainer crowns (D6740) provided on March 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 17, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service 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 March 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and 
panoramic x-ray (D0330) provided on May 12, 2022. 
 
  You asked the Plan to pay for the problem focused limited oral evaluation and panoramic x-ray. You say that 
you feel that the bone graft is very important to prevent decaying of the tooth, since the first tooth next to the 
extraction supports a 5-tooth bridge, and the lone molar behind it would have no support at all. The Plan denied 
your request. The Plan says the problem focused limited oral evaluation is not a covered expense under your 
dental plan. The Plan also says that your benefits for the panoramic x-ray have been satisfied and the frequency 
limitation has been exceeded. 
 
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, problem focused limited oral 
evaluation (D0140) is not among those covered under this benefit. The contract says that full mouth or 
panoramic x-rays share a frequency limitation of one procedure code per calendar year. The record shows that 
you received a complete series of intraoral x-rays (D0210) on May 6, 2022, and your full mouth or panoramic 
x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem 
focused limited oral evaluation (D0140) and panoramic x-ray (D0330) provided on May 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 37248, 37249, 75822 and 75825 provided 
on February 14, 2022. 
  You asked the Plan to pay for procedure codes 37248, 37249, 75822 and 75825. You say that the enrollee had 
multiple exams on this date of service and the attached reports support the level of service. You say that the 
claim should be reconsidered for processing. The Plan denied your request. The Plan says procedure codes 
37248, 37249, 75822 and 75825 are considered inclusive to procedure code 37238. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we have confirmed that code procedure codes 37248, 37249, 75822 and 75825 are column II codes 
to column I code 37238; however, procedure codes 37248, 37249, 75822 and 75825 were billed with a 
modifier.  
 
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 codes 37248, 37249, 75822 and 75825. Our 
reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our 
reviewer found that the operative report describes an angioplasty and stent placement, which include operative 
angiograms or venograms. An angioplasty for treatment would not be coded separately from the same vessel 
that has already been treated with a stent placement. Therefore, these procedures would not be reported 
separately and modifier -59 is not supported. 
 
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 codes 37248, 37249, 75822 and 75825 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 37248, 37249, 75822 and 75825 provided on 
February 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided on March 28, 
2022. 
 
You asked the Plan to pay for the lumbar-sacral orthosis. You say that you have not billed this claim twice. The 
Plan denied your request. The Plan says they have already paid for a back brace provided to the enrollee on 
March 4, 2022. 
 
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 had a lumbar-sacral orthosis at the time the lumbar-sacral orthosis was 
received. This item serves the same purpose as the lumbar-sacral orthosis. Therefore, we decided that the Plan 
does not have to pay for the lumbar-sacral orthosis (L0650) provided on March 28, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has 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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found clinical documentation shows that you require skilled therapy due to complexity of 
functional impairments due to acute diagnosis and requires skilled nursing due to need of close medical 
monitoring from a professional nurse. From a practical standpoint, you require daily services on an inpatient 
basis in a skilled nursing facility, thus 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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an injection procedure for sacroiliac joint, 
anesthetic/steroid, with image guidance including arthrography when performed (27096x2). 
 
You asked the Plan to pre-approve injections. You say that the enrollee was unable to get up from a flexed 
position, reducing him to walk bent over at his most recent office visit. Rates his pain 10/10 severity on a daily 
basis which includes burning and stabbing pain in the right buttock and sacroiliac region. Previous ESI and 
RFIs with no relief which concludes he has failed prolong nonsurgical intervention. The Plan denied your 
request. The Plan says steroid injections in your sacroiliac joints is denied as not medically necessary. 
 
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 injections. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a right positive straight leg raise and has moderate neural foraminal stenosis at 
the right L3-4, bilateral L4-5, L5-S1, pain in his right anterolateral thigh and must walk over bent at his most 
recent office visit. It is not clear that his symptoms are purely sacroiliac related as they are suggestive of spinal 
stenosis. At this time the request for a sacroiliac injection is not the most appropriate treatment for this 
enrollee's condition and there is no failure of recent therapy for his symptoms. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance including 
arthrography when performed (27096x2).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for tumor immunohistochemistry analysis (88360) billed for date 
of service November 10, 2020. 
 
You asked the Plan to pay for tumor immunohistochemistry. You say that this test is supported in the medical 
record. The Plan denied your request. The Plan says this claim is missing a necessary modifier. Code 88360 has 
both a technical component (TC) and a professional component (PC). A modifier is necessary to differentiate 
between the components of this service. When no modifier is billed for either the PC or TC, payment for both 
is requested. However, the TC of this service is not separately payable and is bundled into the facility fee. 
 
The Plan must follow Medicare rules. Medicare rules say that separate payment may not be made for the TC 
component of a physician pathology service furnished to a hospital inpatient or outpatient.  
 
We looked at the file and Medicare rules. Code 88360 is classified as a physician pathology procedure and has 
a PC/TC indicator of 1, meaning that this code has both a technical component and a professional component. 
This service was not billed with a modifier to indicate that only the PC payment is requested. However, the 
records indicate that the sample in this case was collected in an outpatient setting. Therefore, the TC 
component is not separately payable in this case as it is bundled into the outpatient facility fees. Modifier 26 
must be appended to this service in order to request the PC payment only. Based on this information, we 
decided that Medicare rules for coverage of tumor immunohistochemistry have not been met. Therefore, we 
decided that the Plan does not have to pay for tumor immunohistochemistry analysis (88360) billed for date of 
service November 10, 2020.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services received on March 
21, 2022. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that your copayment should be 
zero. The Plan denied your request. The Plan says the claim has been processed correctly per your Plan 
benefits. 
 
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 $40 
copayment for laboratory services received in an outpatient hospital setting.  
 
You have been asked to pay a $40 copayment for the laboratory services. The laboratory services fall within 
the Outpatient Diagnostic Tests benefit category. The laboratory services were received in the outpatient 
hospital setting. 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 the laboratory services received 
on March 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 24, 
2022. 
 
You asked the Plan to pay for procedure code 70450. The Plan denied your request. The Plan says payment for 
code 70450 is bundled into payment for code 70496.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 24, 2022.
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 criteria for admission to the IRF setting have not been met. The enrollee's 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 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 IRF. 
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse (RN) 
(G0299) and home health aide (HHA) services (G0156). 
 
You asked the Plan to pre-approve the skilled nursing and HHA services. You say that you cannot stand for 
long periods of time and still need assistance with the amount of breaks you need to take between tasks. The 
Plan denied your request. The Plan says given the provided documentation, you do not meet the guidelines for 
the requested service which does not appear medically necessary. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 skilled nursing and HHA services. 
Our reviewer says that the requested home health services are not medically necessary. Our physician reviewer 
found the documentation does not support that you require additional skilled nursing services or HHA services 
to provide treatment that is medically necessary. You do not require additional skilled nursing or HHA services 
to effectively provide treatment, care, and/or services in order to improve your condition, perform a 
maintenance program to maintain your condition and/or prevent deterioration. Our reviewer also found that you 
have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. 
 
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 skilled nursing and HHA services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse (RN) (G0299) 
and home health aide (HHA) services (G0156).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87640, 87481, 87653, and 87798 billed for 
date of service January 7, 2022. 
 
You asked the Plan to pay for procedure codes 87640, 87481, 87653, and 87798. The Plan denied your request. 
The Plan says payment for codes 87640, 87481, 87653, and 87798 is bundled into payment for code 87150.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 
87640, 87481, 87653, and 87798 are column II codes to column I code 87150. This claim has not been billed 
with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 87640, 87481, 
87653, and 87798 billed for date of service January 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs LTACH services for 
the enrollee to be safe and fully recover. The Plan denied your request. The Plan says based on Medicare 
guidelines, the requested LTACH services do not meet the requirements for approval. 
 
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 all medically necessary care is being provided in the current acute care setting. 
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
 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 long term acute care hospital (LTACH) services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the non-emergency transportation trip. 
 
You asked the Plan to pre-approve the non-emergency transportation trip. You say that you disagree with the 
denial and would like the Plan to reconsider. The Plan denied your request. The Plan says the requested service 
exceeds the benefit limit of 60 miles. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when service trips to or from a place approved by the Plan and in 
the local service area. You must use the Plans approved vendor and set trips up 48 hours in advance. Routine 
transportation services are provided by a contracted vendor. Trips are limited to 60 miles. We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the trip requested is 
further than the approved 60 miles. Therefore, we decided that the Plan does not have to pre-approve the non-
emergency transportation trip.