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

We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on 
May 19, 2021. 
 
You asked the Plan to pay for the complete series of intraoral x-rays. You say that you would like to appeal this 
service. The Plan denied your request. The Plan says this service is not covered. 
 
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 the 
complete series of intraoral x-rays (D0210) provided on May 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve rheumatology services to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve rheumatology services. You say that you were sent for a second 
opinion/clarification of the diagnosis, but they are now referring you to their rheumatology department to go in-
depth on the new diagnosis and treatment. The Plan denied your request. The Plan says rheumatology services 
are available with in-network providers. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal will not be provided in an emergency or urgent care situation. The Plan is not providing these services and is not making arrangements to provide these services. Therefore, we decided 
that the Plan does not have to pre-approve rheumatology services to be provided by an out-of-network 
provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mammography services represented by code 77065 
provided on March 19, 2021. 
 
You asked the Plan to pay for code 77065. 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 as billed. 
 
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 77065 is a column II code to column I code 77066. Based on the claim submitted, Medicare billing criteria have not 
been met. Therefore, we decided that the Plan does not have to pay for the mammography services represented 
by code 77065 provided on March 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional intraoral periapical x-rays (D0230) provided 
on July 2, 2021. 
 
You asked the Plan to pay for the additional intraoral periapical x-rays. You say that you would like to know 
how it was determined that you exceeded the visit limits when you had not seen a dentist for 18 months. The 
Plan denied your request. The Plan says your benefits for this service have been satisfied and the frequency 
limitation has been exceeded. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, intraoral x-rays are limited to one 
procedure code per calendar year. The record shows that you received a first intraoral periapical x-ray on July 
2, 2021 which was covered by the Plan, and your intraoral x-rays benefit had been exhausted.  
 
  
Therefore, we decided that the Plan does not have to pay for the additional intraoral periapical x-rays (D0230) 
provided on July 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services billed with a secondary 
diagnosis code of J96.01 defined as acute respiratory failure with hypoxia. 
 
You asked the Plan to pay for the inpatient hospital services as billed.. You say that the documentation supports 
the inpatient hospital care as billed. The Plan denied your request. The Plan says there is not enough 
information that supports the services as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. In this case, no medical records were provided to support the services 
as billed. Specifically, there is no documentation that supports the billed secondary diagnosis. Based on this 
information, we decided that Medicare rules for coverage of the inpatient hospital services as billed. have not 
been met. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services billed 
with a secondary diagnosis code of J96.01 defined as acute respiratory failure with hypoxia.
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 transfer to an LTACH is medically 
necessary for the ongoing management of the enrollee's acute care needs. The Plan denied your request. The 
Plan says the criteria for admission to an LTACH are not met. 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 the enrollee appears to be more stable and is tolerating weaning trials and requires 
only short-term additional acute care services to continue weaning. These services can safely be completed at 
the current facility. The enrollee does not require services at the LTACH that are not already available at the 
current facility. There are no services at the LTACH that the enrollee requires that are not already available and 
covered at the current facility. Therefore, LTACH services are considered not medically necessary as a transfer would not provide a clinical advantage at this time. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral x-rays provided on May 19, 2021. 
 
You asked the Plan to pay for the intraoral x-rays. You say that it was necessary to go to a different office and 
you were considered a new patient. You say that you didn't authorize the dentist to do anything that wasn't 
covered, and the denial should be reconsidered. The Plan denied your request. The Plan says the services are 
not covered benefits. 
 
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 pay for the 
intraoral x-rays provided on May 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on June 2, 2021. 
 
You asked the Plan to pay for the dental services. 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 as the provider as 
opted out of the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the dental 
services provided on June 2, 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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says IRF care is not medically necessary. 
 
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. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 is not medically 
necessary. 
 
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 the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the documentation does support a need for physical and/or occupational 
therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 
 
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 provide coverage for the acute inpatient hospital care to be provided 
after a total right reverse shoulder arthroplasty with tenodesis. 
 
You asked the Plan to provide coverage for acute inpatient hospital care. The Plan denied your request. The 
Plan says the arthroplasty procedure is currently approved as an ambulatory outpatient procedure. There is no 
documentation provided to support the expectation that the enrollee will require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 provide coverage for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found that the record indicates that the enrollee is scheduled for a total right 
reverse shoulder arthroplasty with tenodesis. The record does not document that the treating physician has a 
reasonable expectation of a length of stay spanning 2 or more midnights. The enrollee may be admitted for 
observation. The elements of the coverage rule are not satisfied. The requested service is not recommended 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to provide coverage for the acute inpatient hospital care to be provided after a total right 
reverse shoulder arthroplasty with tenodesis.
Appeal type: Surgery
Decision: Favorable

 We decided that the Plan has to pay for the left shoulder surgery provided on May 4, 2021, billed with codes 29827-22-LT, 29823-LT, and 29826-LT.  
You asked the Plan to pay for the left shoulder surgery as billed. You say that it is felt this is billed correctly and should be paid. The Plan denied your request. 

The Plan says that the records do not support any of the billed codes. No payment can be made for this surgery as billed.

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, CPT code 29823 is defined as Arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies]).  Code 29826 is defined as  Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when performed (List separately in addition to code for primary procedure) Code 29827-22 is defined as Arthroscopy, shoulder, surgical; with rotator cuff repair, increased procedural service.  

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 pay for the left shoulder surgery as billed. Our reviewer says that review of the operative report supports all codes billed, including the use of modifier -22 for increased procedural services. Our reviewer found the record indicates that the enrollee underwent a rotator cuff repair.  The operative note indicates that increased time was required due to poor bone and multiple techniques required for accomplishing repair of the rotator cuff. This supports code 29927-22. The operative note also does describe the performance of a partial bursectomy, subacromial decompression and acromioplasty, supporting code 29826. Finally, the note describes debridement of the labrum, articular sided rotator cuff tissue, and the subscapularis. This would support the use of code 29823.  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 left shoulder surgery as billed have not been met. Therefore, we decided that the Plan has to pay for the left shoulder surgery provided on May 4, 2021, billed with codes 29827-22-LT, 29823-LT, and 29826-LT.   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 genetic testing represented by code 81455 provided on 
April 27, 2021. 
 
You asked the Plan to pay for code 81455. 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 providers must report services correctly. 
 
We looked at the file and Medicare rules. Medicare says that genetic testing submitted under code 81455 will 
be denied as not medically necessary as it is unlikely to impact therapeutic decision-making in the clinical 
management of the enrollee. Therefore, we decided that the Plan does not have to pay for the genetic testing 
represented by code 81455 provided on April 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator for travel use. 
 
You asked the Plan to pre-approve portable oxygen concentrator. You say that the enrollee needs to be able to 
leave her home to commute to appointments and is going on a long road trip. The Plan denied your request. 
The Plan says the denial of authorization for this device is correct, because this device is being requested 
primarily for use outside of the home which is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a portable oxygen concentrator for travel use.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a segmental pneumatic compression device (PCD). 
 
You asked the Plan to pre-approve the requested device. You say that the enrollee has increased abdominal 
swelling. The Plan denied your request. The Plan says there has been no documented trial and failure of a PCD 
coded E0651. 
 
The Plan follows Medicare rules. Medicare rules say that pneumatic compression devices are only covered 
under certain medical indications.  
 
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 requested device. Our physician 
reviewer found that in this case, the record indicates the enrollee has lymphedema with extension to the trunk  
The record does not indicate that the enrollee has trialed and failed a E0651 device. The coverage criteria have 
not been met. Therefore, the requested services are not medically reasonable or 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 requested device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a segmental pneumatic compression device (PCD).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care services coded 99232 provided 
on February 14, 2021. 
 
You asked the Plan to pay for the subsequent hospital care services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
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, the CPT Code Manual definition of code 99232 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded 
problem focused interval history; An expanded problem focused examination; Medical decision making of 
moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor 
complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
 We find that CPT code 99232 is not supported in the medical record. Specifically, this service was already 
billed for this date of service by the same provider. The Plan has previously processed this code for this date of 
service. It is inappropriate to bill this service more than once per day. Based on this information, we decided 
that Medicare rules for coverage of the subsequent hospital care services have not been met. Therefore, we 
decided that the Plan does not have to pay for the subsequent hospital care services coded 99232 provided on 
February 14, 2021.