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

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee would benefit from therapy at the SNF 
for strengthening and endurance. The Plan denied your request. The Plan says 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 the medical records provided there is no documentation that the enrollee requires the services on an 
inpatient basis, only in a SNF setting. Records do not document services in the long-term care facility on a part 
time basis are not appropriate in this case, if needed. 
 
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 SNF care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9342 billed for date of service February 19, 
2022, to March 20, 2022. 
 You asked the Plan to pay for the services provided. You say that the records validate the procedure code for 
service. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9342 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9342 is not valid for Medicare purposes. 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 procedure code S9342 billed for date of service February 19, 2022, to March 20, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
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 you do not need skilled nursing, or skilled therapy on a daily basis. The Plan states 
your care could be provided at a lower level of care like in a long-term care facility or at home with home 
health services. 
 
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 there is no documentation that you require the services on an inpatient basis, only in a SNF setting. 
Records do not document services in the home with home health care or in a 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary services provided on August 12, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for domiciliary services. You say that you would like to request reconsideration of 
the denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization 
is required prior to an out-of-network visit. 
 
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 domiciliary services provided on August 12, 2021, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy (PT) services provided 
from December 7, 2021, to December 17, 2021. 
 
You asked the Plan to waive the copayments for the PT services. You say that you were informed the services 
would be covered. 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 $40 
copayment for each therapy visit.  
 
You have been asked to pay a $40 copayment for each therapy visit, for a total of $80. The PT services fall 
within the Outpatient Rehabilitation 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 copayments 
for physical therapy (PT) services provided from December 7, 2021, to December 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for DME provided on April 4, 2022. 
 
You asked the Plan to waive the coinsurance for DME. You say that if your mother had been taken care of and 
not neglected, she wouldn't have needed the equipment. The Plan denied your request. The Plan says the 
coinsurance applied 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). The enrollees contract with the Plan clearly says that enrollees 
must pay 20% coinsurance for Medicare-covered durable medical equipment. 
 
The enrollee has been asked to pay $37.60 which is 20% of the allowed amount for the DME. The allowed 
amount is $187.99(20% x $187.99= $37.60). DME falls within the Durable Medical Equipment (DME) and 
Related Supplies benefit category. This means that the enrollee has been asked to pay the correct amount based 
on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon 
enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for DME 
provided on April 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), expandable controller 
harness (E2313) and a power seat elevation feature (E2300) for the enrollee. 
 
You asked the Plan to pre-approve an expandable controller, expandable controller harness and a power seat 
elevation feature. You say that these items are medically necessary. The Plan denied your request. The Plan 
says that the member's upper limb strength and function are adequate for the member to be able to control the 
power options using their own switches.  
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules say that a power seat elevation feature is non-covered because it is 
not primarily medical in nature. 
 
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 an expandable controller and an 
expandable controller harness. Our reviewer says that an expandable controller and expandable controller 
harness are not considered medically reasonable and necessary in this case. Provided records document that the 
enrollee has 3+/5 to 4-/5 upper extremity strength, and he can perform self-feeding and upper body dressing, 
thus indicating he has adequate upper extremity strength and function to operate the wheelchairs power 
options with their own switches. Our physician reviewer found that the enrollee's condition does not meet 
criteria for coverage of an expandable controller and expandable controller harness. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller, expandable controller harness and a power seat 
elevation feature have not been met. Therefore, we decided that the Plan does not have to pre-approve an 
expandable controller (E2377), expandable controller harness (E2313) and a power seat elevation feature 
(E2300) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OsteoCal Allograft for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of the OsteoCel Allograft in 
the setting of a lumbar spine fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. There is limited 
published, large-scale, long-term peer-reviewed literature that shows this request to be an effective and/or safe 
treatment for the enrollee's pathology. Our physician reviewer found that the enrollee's condition does not meet 
criteria for coverage of these services.  
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 OsteoCal Allograft for the enrollee.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown on tooth #6, 8, and 9 (D2751). 
 
You asked the Plan to pre-approve crowns. You say that you are in pain and these services are medically 
necessary. The Plan denied your request. The Plan says that the teeth do not appear to have significant 
breakdown due to decay or trauma. 
 
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 did not provide the clear medical records they used in making their 
decision. The Plan did not support their decision to deny your request. Therefore, we decided that the Plan has 
to pre-approve a crown on tooth #6, 8, and 9 (D2751).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for shower/bath chair provided on January 5, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for shower/bath chair. You say that the services provided were medically necessary. 
The Plan denied your request. The Plan says the provider is out-of-network, and it was determined these 
services can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 shower/bath chair provided on January 5, 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 an office visit provided on January 27, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 an office visit provided on January 27, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the full cast high noble metal crown (D2790) provided on 
January 31, 2022, by the out of network provider. 
 
You asked the Plan to pay for the dental service. You say that you were given a list of in network providers. 
You say that none of them were taking new clients. You say that your crown broke and fell off. You say that 
you did not want to lose your tooth. You also say that the provider in this case works with low-income clients. 
The Plan denied your request. The Plan says dental services received out of network are not covered. The Plan 
also says there were in network providers available. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the dental service received out of 
network is not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the full cast high noble metal crown (D2790) provided on January 31, 2022, by the out of network 
provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten (10) home health physical therapy visits (CPT code 
G0151 x10). 
 
You asked the Plan to pre-approve the home health physical therapy visits. You say that the services are 
necessary. The Plan denied your request. The Plan says the medical record does not document a clearly evident need for the services of a skilled physical therapist. The Plan states the enrollee has already been educated on a 
home exercise program and there is no documentation of an active or acute on chronic condition that would 
necessitate a new program. 
 
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 physical therapy visits. 
Our physician reviewer found the documentation does not support that the enrollee requires additional skilled 
rehabilitation services to provide treatment that is medically necessary. The enrollee does not require additional 
skilled rehabilitation services to effectively provide treatment, care, and/or services in order to improve the 
enrollee's condition, perform a maintenance program to maintain the enrollee's condition and/or prevent 
deterioration. The enrollee has been medically stable without any recent exacerbations of chronic medical 
problems or hospitalizations. The requested home health services are 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 the home health physical therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve ten (10) home health physical therapy visits (CPT code 
G0151 x10).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 19, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 an office visit provided on January 19, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital visits on January 31, 
2022, and February 7, 2022. 
 
You asked the Plan to waive the copayment for outpatient hospital services. You say that the enrollee does not 
feel responsible for paying for the services. The Plan denied your request. The Plan says the cost-share 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $50 copayment per visit for Medicare-covered services performed in an outpatient hospital setting.  
 
The enrollee has been asked to pay a $50 copayment for outpatient hospital services. The services at issue fall 
within the outpatient hospital services benefit category. The enrollee received care in an outpatient hospital 
facility. This means that the enrollee has been asked to pay the correct amount based on the contract with the 
Plan.  
 This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, 
we decided that the Plan does not have to waive the copayment for outpatient hospital visits on January 31, 
2022, and February 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789-59 billed for date of service July 26, 
2021. 
 
You asked the Plan to pay for code 83789. You say that this service was billed appropriately and should be 
paid separately. The Plan denied your request. The Plan says the payment for 86789 is included in the payment for G0480. Although 86789 was billed with a modifier to receive separate payment, the records do not support 
that this modifier was used appropriately as 86789 was not separate and distinct from G0480. 
 
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 83789 
is a column II code to column I code G0480; however, 83789 was 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 code 83789. Our reviewer says that 83789 is not supported 
for separate payment. Our reviewer found that the medical record includes a urine drug screen. In this case, 
separate reimbursement for specimen validity testing for a urine drug screen is not supported. This procedure 
would be inclusive to G0480. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 83789 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 83789-59 billed for date of service July 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on January 5, 2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that the doctor was not available to see 
the enrollee that day so the charge should be waived. The Plan denied your request. The Plan says the 
copayment applied 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). The enrollees contract with the Plan clearly says that enrollees 
must pay $10 copayment for each covered visit or consultation in an outpatient location with your PCP or other 
primary care provider.  
 
 
 
 The enrollee has been asked to pay $10 copayment for an office visit. Office visits fall within the 
Physician/Practitioner Services, Including Doctors Office Visits benefit category. This means that the enrollee 
has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for an office visit provided on January 5, 2022.