Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve continuation of SNF care from August 15, 2022, forward. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says that the stay is not medically necessary based on SNF criteria. 
 
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 physician reviewer 
found daily skilled services in a SNF are medically necessary based on documentation. 
 
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 continuation of 
SNF care from August 15, 2022, forward.  
 
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 the Tempus gene panel provided on July 19, 2021, billed 
with codes 81206 and 81292. 
 
You asked the Plan to pay for the Tempus gene pane. You say that this should be covered. The Plan denied 
your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the Tempus gene pane 
have not been met. Therefore, we decided that the Plan does not have to pay for the Tempus gene panel 
provided on July 19, 2021, billed with codes 81206 and 81292.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and panoramic 
radiographic image (D0330) provided on February 23, 2022. 
 
You asked the Plan to pay for the dental services. 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 both the comprehensive oral evaluation (D0150) and panoramic image (D0330) were 
exhausted on date of service October 28, 2021. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation (D0150) and panoramic radiographic image (D0330) provided on February 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by a participating provider on 
November 5, 2021. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says these services have been correctly denied. 
 
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. The Plan covers covered 
dental services when the services are provided by an in-network provider. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pay for 
dental services provided by an out-of-network provider on November 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for out-of-network (OON) laboratory services 
provided on December 13, 2021. 
 
You asked the Plan to waive the deductible for the OON lab services. You say that this provider was always in-
network and that has not changed. The Plan denied your request. The Plan says the correct amount was applied 
to your deductible. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $250 out-of-network deductible which applies to certain items and 
services.  
 
 
 
 
 
 
 
 
 The out-of-network lab services fall within the Outpatient Diagnostic Tests and Therapeutic Services and 
Supplies benefit category. The file shows that the provider was not a network provider on the date of service. 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is $250 out-of-network 
deductible which applies to certain items and services. This cost sharing is a contractual obligation that had not 
been met at the time the OON lab services were received on December 13, 2021. Therefore, we decided that 
the Plan does not have to waive the deductible for out-of-network (OON) laboratory services provided on 
December 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 28, 2021, billed with 
codes 81206, 81235 and 81321. 
 
You asked the Plan to pay for genetic testing. You say that this testing is useful to patients. The Plan denied 
your request. The Plan says this was not billed correctly. 
 The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of genetic testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on June 28, 
2021, billed with codes 81206, 81235 and 81321.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for scaling in moderate or severe gingival inflammation (D4346) 
provided by a participating provider on December 30, 2021. 
 
You asked the Plan to pay for scaling in moderate or severe gingival inflammation. You say that you needed 
these services done. The Plan denied your request. The Plan says the rendered dental work has been correctly 
denied. 
 
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 scaling in 
moderate or severe gingival inflammation (D4346) provided by a participating provider on December 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the co-surgeon services (36556-62) provided on April 1, 2021. 
 
You asked the Plan to pay for the co-surgeon services (36556-62). You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a co-surgeon indicator of "0" means payment 
adjustment rules for two or team surgeons do not apply. In this case, code 36556 has a co-surgeon indicator of 
"0." This means that co-surgeons for this procedure are not permitted, and no separate payment will be made. 
Therefore, we decided that the Plan does not have to pay for the co-surgeon services (36556-62) provided on 
April 1, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services and electrocardiogram (EKG) 
provided in the emergency department (ED) on March 11, 2022. 
 
You asked the Plan to pay for the ED services. You say that the diagnosis codes reported are correct and should 
allow payment for this claim. The Plan denied your request. The Plan says this claim has two diagnoses which 
cannot be reported together. 
 
The Plan must follow Medicare rules. Medicare rules say that providers are required to bill in accordance with 
ICD-10 guidelines. These guidelines indicate that an Excludes1 note on a diagnosis code indicates that it 
cannot be billed with the listed other diagnosis.  
We looked at the file and Medicare rules. This claim was billed with diagnosis codes R09.02 and J96.90. The 
code base R09 has an Excludes1 note for respiratory failure reported under code base J96. This means that 
reporting R09.02 precludes reporting for J96.90. Based on this information, we decided that Medicare rules for 
coverage of the ED services have not been met. Therefore, we decided that the Plan does not have to pay for 
the critical care services and electrocardiogram (EKG) provided in the emergency department (ED) on March 
11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the comprehensive oral evaluation - new or established 
patient (D0150), prophylaxis - adult (D1110), bitewings - four radiographic images (D0274), and panoramic 
radiographic image (D0330) provided April 13, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay more for the dental services. You say that your plan includes a dental rider which 
covers these services. The Plan denied your request. The Plan says you are responsible for any charged amount 
above the Plan's 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 Plan's coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network provider's charges and the Plan's 
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 comprehensive oral evaluation - new or 
established patient (D0150), prophylaxis - adult (D1110), bitewings - four radiographic images (D0274), and 
panoramic radiographic image (D0330) provided April 13, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ILR (CPT code 33285). 
 
You asked the Plan to pre-approve the ILR. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the requested service is not covered by Medicare or the Health Plan. 
 
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 ILR. Our physician reviewer found 
there is no documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or any 
other apparent indication for an ILR.  In summary, there is insufficient documentation to support the medical necessity for insertion of an ILR in this 
enrollee's clinical management. 
 
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 ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve ILR (CPT code 33285).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a specialist office visit and alcohol or 
substance abuse counseling provided from January 16, 2020, to June 4, 2020. 
 
You asked the Plan to waive the copayments for the specialist visit and counseling services. You say that you 
were not informed of any copayments at the times of service. You say that you received the bill two and a half 
years later. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
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 $35 
copayment for each specialist visit. 
 
 Your contract with the Plan also clearly says that you must pay a $35 copayment for each substance abuse 
therapy visit. 
 
You have been asked to pay a $35 copayment for the specialist visit. The specialist visit falls within the 
Physician/Practitioner Services, Including Doctor's Office Visits benefit category. You have also been asked to 
pay a $35 copayment for each of the 5 counseling services. The counseling services fall within the Outpatient 
Substance Abuse Services benefit category. The total for all services is $210. 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 copayments for a specialist office visit and alcohol or substance abuse counseling provided from 
January 16, 2020, to June 4, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the HH OT visits (CPT code G0152 x5). 
 
You asked the Plan to pre-approve the home health occupational therapy visits. You say that the services are 
necessary. The Plan denied your request. The Plan says they previously approved visits to work on the 
enrollee's goals and a home exercise program. The Plan states continuing this program can help the enrollee 
maintain their current level of function or improve further. The Plan states the enrollee's records do not support 
the need for a skilled occupational therapist to make more home visits. 
 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 home health occupational therapy 
visits. Our physician reviewer found the health plans denial should be upheld. The enrollee does not have 
documented, ongoing, HH OT needs. The enrollee is functioning at a level commiserate with a lower level of 
care. As such, the requested, ongoing, HH OT services are not medically necessary or reasonable. 
 
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 home health occupational therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the HH OT visits (CPT code G0152 x5).
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 are necessary. The Plan denied your 
request. The Plan says 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 
services are not medically necessary. Our physician reviewer found although further rehabilitation services 
would be appropriate to improve function, as a practical matter, the intermittent skilled services can be 
provided at a lower level of care than a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periapical x-rays (D0220, D0230) provided on April 15, 2022. 
 
You asked the Plan to pay for x-rays. You say that your new dentist needed to take new x-rays. The Plan 
denied your request. The Plan says periapical x-rays (D0220, D0230) are not covered by your routine dental 
benefits. 
 
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 periapical 
x-rays (D0220, D0230) provided on April 15, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a computed tomography (CT) scan of the 
lumbar spine and a lumbar injection myelography provided on March 1, 2022. 
 
You asked the Plan to waive the copayments for the CT scan and myelography. You say that you feel you 
should not have to pay for both services. The Plan denied your request. The Plan says you have been charged 
the correct cost sharing amount. 
 
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 $150 
copayment per day, per provider, for diagnostic radiology services, including CT scans. 
 
Your contract with the Plan also clearly says that you must pay a $290 copayment for each outpatient hospital visit. 
 
You have been asked to pay a $150 copayment for the CT scan. The CT scan falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. You have also been asked to pay a 
$290 copayment for the myelography. The myelography is considered a surgical procedure and falls within the 
Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers benefit category. The total for all services is $440. 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 copayments 
for a computed tomography (CT) scan of the lumbar spine and a lumbar injection myelography provided on 
March 1, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on April 
30, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you cannot afford 
the copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
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 $250 
copayment for each one-way ambulance trip.  
 
You have been asked to pay $238.54, which is less than the $250 copayment for the ambulance transportation. 
The ambulance transportation falls within the Ambulance Services benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for ambulance transportation provided on April 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
February 27, 2022, to March 5, 2022. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you had fluid around your lungs 
that should have been drained by the ER. The Plan denied your request. The Plan says you have been charged 
the correct cost sharing amount. 
 
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 per 
day for days 1-5 and $0 per day for days 6-90 for each inpatient admission.  
 
The file shows that you were in the hospital from February 27, 2022, to March 5, 2022. Therefore, you have 
been asked to pay $250 per day for days 1-5 of inpatient care. The total for your stay is $1,250 ($250 
copayment x 5 days = $1,250). The inpatient care falls within the Inpatient Hospital Care 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 inpatient hospital care provided 
from February 27, 2022, to March 5, 2022.