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

 
We decided that the Plan does not have to pre-approve complete mandibular and maxillary dentures. 
 
You asked the Plan to pre-approve complete mandibular and maxillary dentures. You say that your current 
dentures are causing you pain. The Plan denied your request. The Plan says that his service is only covered 
once per every 5 plan years. 
 
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 one complete 
upper and one complete lower denture every five plan years.  
 
We looked at the file and Medicare rules. The file indicates you received a complete maxillary (upper) and a 
complete mandibular (lower) denture on September 17, 2019, which is less than five years ago. Based on this 
information, we decided that the Plan's rules for coverage of complete mandibular and maxillary dentures have 
not been met. Therefore, we decided that the Plan does not have to pre-approve complete mandibular and 
maxillary dentures.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the central venous catheter insertion rendered on November 
9, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says payment is included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that all additional medical or surgical services required of 
the surgeon during the postoperative period of the surgery are included in the global surgical package. 
 
We looked at the file and Medicare rules. Billed procedure code 36556 was performed within the 10 day global 
surgical period for minor procedure 36589 performed on November 6, 2021. Code 36556 was related to the 
original procedure and is not separately payable.  
 
 
 
 Therefore, we decided that the Plan does not have to pay for the central venous catheter insertion rendered on 
November 9, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90791) provided on 
January 31, 2022. 
 
You asked the Plan to pay for the diagnostic evaluation. You say that this service was necessary and should be 
paid. The Plan denied your request. The Plan says this provider is not enrolled in Medicare, and therefore 
cannot receive Medicare payment. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the psychiatric diagnostic evaluation 
(90791) provided on January 31, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic activities, and therapeutic procedures provided 
on January 3, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for therapeutic activities, and therapeutic procedures. You say that the denials do not 
acknowledge the medical necessity of the medical services provider, and the doctor's approval of the 
rehabilitation services was obtained as evidenced by the Plan's doctor request. The Plan denied your request. 
The Plan says the provider is out-of-network, and the services were not urgent/emergent. 
 
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 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 therapeutic activities, and therapeutic procedures 
provided on January 3, 2022, 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 home INR monitoring rendered on January 18, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural 
service. Specifically, the records do not show that the services were performed during a separate encounter. 
Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier 
have not been met. Therefore, we decided that the Plan does not have to pay for the home INR monitoring 
rendered on January 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on February 5, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the claim was 
processed correctly. 
 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 looked at the file and the rules. The claim at issue was billed with code G0452, which has a status indicator 
of B. When a B code is billed on an outpatient hospital claim, the whole claim is returned to provider. 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 services provided on February 5, 2021.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 are medically stable and do not need PM&R physician close supervision 3 times 
per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical 
conditions. At the current functional level, you do not require 3 hours a day five days a week of IRF therapies 
with interdisciplinary management. Your rehab needs can be provided in an alternate and low intensity setting 
such as in a skilled nursing facility (SNF). Recommend continuation of SNF rehab. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care. 
 
You asked the Plan to pre-approve inpatient psychiatric care. You say that the records provided support the 
need for inpatient psychiatric care. The Plan denied your request. The Plan says the guidelines for coverage 
have not been met. The Plan says that the enrollee could be treated safely and effectively at a lower level of 
care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
 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 inpatient psychiatric care. Our reviewer 
says that the criteria for coverage have not been met. Our physician reviewer found the enrollee was admitted 
to the acute inpatient psychiatric hospitalization on May 7, 2022, with Schizoaffective Disorder Bipolar Type. 
It was not expected this enrollee would improve in a reasonable period of time beyond the dates in question as 
he was not showing any dangerousness to self or others, auditory or visual hallucinations and without 
aggressive behaviors while not showing any acute threats of safety. It did not appear medically necessary and 
reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care 
beyond the dates in question as he did not have any suicidal or homicidal thoughts, auditory or visual 
hallucinations or abnormal behaviors. It did not appear that the services for the dates in question were 
reasonably expected or medically necessary to improve the enrollees condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient psychiatric care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the EKG recording with report provided on 
January 21, 2022. 
 
You asked the Plan to waive the copayment for the EKG recording. You say that it should be covered. The 
Plan denied your request. The Plan says copayment was applied correctly. 
 
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 basic radiological services at a specialists office. 
 
You have been asked to pay a $35 copayment for the EKG recording. The EKG recording 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 the electrocardiographic (EKG) recording with 
report provided on January 21, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not 
meet 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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found records do not document the need 
for intravenous medications, new tube feeding, ostomy care or daily complex wound care. Although records 
document the enrollee is very limited functionally, provided records do not document a significant 
improvement in the enrollees functional status after three weeks of daily inpatient skilled therapy services. 
Part time therapy services now appear appropriate as further improvement is not predictable in a reasonable 
timeframe. The enrollee does not require the services on an inpatient basis, only in a skilled nursing facility 
setting. Records do not document that services in the long-term care facility on a part time basis are not 
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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the services provided on September 23, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the services were 
not authorized. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan argues that the out-of-network services were not authorized. However, 
the enrollee in this case has a PPO plan, which allows for use of out-of-network providers. The Plan has not 
provided documentation substantiating its denial. Therefore, we decided that the Plan has to pay for the 
services provided on September 23, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for special stain including interpretation and report (88312) 
surgical pathology, gross and microscopic examination (88305) provided on December 22, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that patients do not come to your lab so they are 
not using out of network benefits as their participating doctor sends you the specimen to process. The Plan 
denied your request. The Plan says enrollees must receive their medical services from an in-network provider 
with the exception being urgent or emergent services. Non-emergent services with non-contracted providers 
require prior authorization before services being rendered. 
 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 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 special stain including interpretation and report 
(88312) surgical pathology, gross and microscopic examination (88305) provided on December 22, 2021 by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (77002) provided November 29, 2021. 
 
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says this code is an addon code billed without a primary procedure. 
 
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 77002 
is an add-on code and has not been billed with an appropriate primary procedure code.  Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for radiology services (77002) provided November 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a specialist office visit and an 
electrocardiogram (EKG) provided on January 11, 2022. 
 
You asked the Plan to waive the copayments for the office visit and EKG. You say that EKG's were not 
included in past plans. 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 level 1 specialist services. Your contract with the Plan also clearly says that you must pay a $75 copayment for diagnostic procedures and 
tests, such as EKG's. 
 
You have been asked to pay a $35 copayment for the office visit. The office visit falls within the 
Physician/Practitioner Services, Including Doctor's Office Visits benefit category. You have also been asked to 
pay $12.58 for the EKG, which is less than the $75 copayment. The EKG falls within the Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies benefit category. The total for the visit is $47.58. 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 an electrocardiogram (EKG) provided on 
January 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81479) provided October 1, 2021. 
 
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 this test was ordered for screening purposes and is not covered.  
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, CxBladder, was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for lab 
services (81479) provided October 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vascular surgery to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve these services. You say that you need to receive this treatment as soon as 
possible to avoid leg amputation. The Plan denied your request. The Plan says that there are participating 
providers available to perform these services. 
 
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 
vascular surgery to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for operation room services provided on 
January 17, 2022. 
 
You asked the Plan to waive the coinsurance for operation room services. You say that because of having 3 
hernias that needed to be repaired, the provider recommended this procedure be done in a hospital instead of an 
outpatient surgical site. You also say you were told your deductible would be $150. The Plan denied your 
request. The Plan says you were 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 20% 
coinsurance for surgery performed at an outpatient hospital facility.  
 
 You have been asked to pay $1,032.15, which is 20% coinsurance of the allowed amount for operation room 
services ($5,160.74 allowed amount x 20% coinsurance = $1,032.15). Operation room services falls within the 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
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 coinsurance for operation room services 
provided on January 17, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found you have age-related osteoporosis 
without a current pathological fracture. You have been receiving medical therapy with Reclast since 2018. 
Regular bone density tests have demonstrated that your bone density has improved. You are taking Reclast 
without any problem; therefore, changing to Prolia is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia.