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

 
We decided that the Plan does not have to waive the copayment for X-rays of the spine provided on April 29, 
2022. 
 
You asked the Plan to waive the copayment for the X-rays. You say that you were not charged for these 
services before. 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 basic imaging service, such as X-rays and ultrasounds.  
 
 
 
 
 
 
 You have been asked to pay a $35 copayment for the X-rays. The X-rays fall 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 X-rays of the spine provided on April 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
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. 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 services are not medically necessary. Our physician reviewer found the enrollee has bilateral knee pain. 
Genicular nerve blocks and genicular nerve radiofrequency ablations are considered investigational and not 
medically necessary for the treatment of chronic knee pain. 
 
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 a genicular nerve block.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal and replacement of the right breast implant for 
the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that the procedure for both implants is medically 
necessary. The Plan denied your request. The Plan says this portion of the requested procedure is considered 
cosmetic. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the the record indicates that the enrollee has a history of breast cancer and underwent mastectomy in 
the past. The record as provided is insufficient to establish that the coverage criteria are satisfied. The record 
provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the 
requested service. The elements of the coverage criteria are not satisfied.  
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve removal and replacement of the right breast implant for the enrollee.
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 19, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. 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 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services from April 22, 
2022, to April 29, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital services. You say that you should not be 
responsible for this copayment. The Plan denied your request. The Plan says the 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 $200 per 
day for days 1 to 5 for inpatient hospital services.  
 
You have been asked to pay $1000 ($200 x 5 days) for inpatient hospital services. Inpatient hospital services 
fall 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 services from April 22, 2022, 
to April 29, 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 you are requesting LTACH services for 
the enrollee. The Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
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 the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving care. 
 
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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lingual frenectomy (D7962). 
 
You asked the Plan to pre-approve a lingual frenectomy (D7962). You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says dental code D7962 is not covered under 
the Plan's supplemental dental benefit. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
lingual frenectomy (D7962).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair and accessories 
(K0823, K0108, E1028). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the enrollee has had a 
change in health with increased weakness and decreased endurance. His wife can no longer push him in the 
wheelchair. The power wheelchair is medically necessary. The Plan denied your request. The Plan says 
approval for a power wheelchair is not medically necessary. The enrollee is currently using an ultra-lightweight 
manual wheelchair and is able to propel within the in-home distance for ADL. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 
 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 a power wheelchair and accessories. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has a 
mobility deficit that impairs mobility related activities of daily living (MRADLs) such as toileting, feeding, 
grooming and bathing in customary locations within the home. The documentation indicates that the enrollee's 
condition is ameliorated by a manual wheelchair. He can propel an optimally configured manual wheelchair at 
a speed, distance, and endurance that allows for MRADL participation in customary areas of the home. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 2 standard power wheelchair and accessories (K0823, 
K0108, E1028).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a sleep study provided on December 23, 
2021. 
 
You asked the Plan to waive the copayment for a sleep study. You say that you should not be responsible to 
pay this. The Plan denied your request. The Plan says the cost share has been 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 for diagnostic services, 
enrollees must pay a $45 copayment per provider, per date of service.  
 
You have been asked to pay $45 for a sleep study. A sleep study 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 a sleep study provided on December 23, 2021.  
 Your complaint about being unable to sleep at night and being disappointed with the results of the sleep study 
is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by 
the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is ready and stable for 
transfer and meets Medicare guidelines for LTACH admission. The Plan denied your request. The Plan says 
the enrollee does not require extensive or complex wound care management by skilled nursing of at least 6.5 
hours per day. There is no documentation that the enrollee will benefit from and improve with LTACH 
management. The enrollee's medical needs are being met in the current acute setting. The LTACH would add 
no additional services. With additional time in the current setting, clinical stability can be ensured such that the 
appropriate lower level of care can be determined. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. 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 health plan. The health 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 the LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve partial psychiatric hospitalization. 
 
You asked the Plan to pre-approve partial psychiatric hospitalization. You say that the services are medically 
necessary. The Plan denied your request. The Plan says the services at issue are 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 partial psychiatric hospitalization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this enrollee does not appear to require partial hospitalization treatment as 
he was not showing any psychological or psychiatric illness and does not require this intensity of treatment. 
Based upon review the records provided, this enrollee does not meet the criteria for treatment at partial 
hospitalization level of care and could have been treated in a lesser restrictive setting as he was not showing 
any suicidal or homicidal ideation and was not showing any psychosis or aggressive behaviors. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of partial psychiatric hospitalization have not been met. Therefore, we decided that 
the Plan does not have to pre-approve partial psychiatric hospitalization.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 75726, 75774 and G0269 billed for date of 
service November 2, 2021. 
 
You asked the Plan to pay for procedure codes 75726, 75774 and G0269. You say that these services were 
reported correctly and are supported in the medical records provided. The Plan denied your request. The Plan 
says these services are not supported in the records with the modifiers used. The Plan also argues that code 
G0269 has a status indicator which indicates payment for this service is always bundled into the payment for 
another service or 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. 
 
We find that procedure code G0269 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code G0269 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of G0269 have not been met. 
 
In this case, we have confirmed that codes 75726 and 75774 are both column II codes to column I code 37242; 
however, 75726 and 75774 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 75726 and 75774. Our reviewer says that 
codes 75726 and 75774 are not supported as billed for separate payment. Our reviewer found the procedure 
report does not support that these services are separate procedures from the approved procedure code 37242. 
The documentation does not support that separate and distinct diagnostic studies prior to treatment were 
provided, and in addition two units of 75726 and three units of 75774 cannot be verified. The payment for 
intervention includes all radiological services performed to complete the intervention. 
 
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 75726, 75774 and G0269 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 75726, 75774 and G0269 billed for date of 
service November 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 15, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on February 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee fully meets Medicare criteria 
for LTACH admission. The Plan denied your request. The Plan says the records do not show that the enrollee 
has a need for continued treatments and care that can only be given in a hospital setting. When the enrollee is 
ready to leave the hospital, they can safely receive this care in another setting, such as a skilled nursing facility 
or at home with home health services. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where he/she is currently receiving care. 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 health plan. The health 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 the LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF admission and services is medically 
necessary. The Plan denied your request. The Plan says the records do not show that the enrollee is expected to 
improve a lot in a reasonable time. The services the enrollee needs can be provided safely in other settings like 
a skilled nursing facility, home with home health services or home with outpatient therapy. 
 
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 enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for syncope and a urinary tract infection. Medical problems are stable. There are no 
complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this 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 IRF admission and services.