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

We decided that the Plan does not have to pre-approve an office visit with an out-of-network dentist to fix your 
implants. 
 
You asked the Plan to pre-approve out-of-network dental care. You say that you would like to use this dentist 
as they were recommended to you. The Plan denied your request. The Plan says the requested provider is not 
part of the Plan's specified dental network. There are providers in-network who can provide the necessary care. 
 
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. The Plan only covers dental 
care when it is received from a provider in the Plan's dental network as specified in the contract. The only 
exception is emergency dental care.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, items or services provided outside the 
Plan's specified dental network are not among those covered under this benefit. The Plan has provided 
information for multiple in-network providers who would be able to provide this care. Therefore, we decided 
that the Plan does not have to pre-approve an office visit with an out-of-network dentist to fix your implants.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services and electrocardiogram provided on 
December 13, 2020. 
 
You asked the Plan to pay for the critical care services and electrocardiogram. You say that the member did not 
have active hospice at the time of service. You say that this date of service was processed incorrectly. The Plan 
denied your request. The Plan says Original Medicare is responsible for payment.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on December 12, 2020. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the critical care 
services and electrocardiogram provided on December 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the ultrasound guidance, two injections, 
and the office visit you had with a rheumatologist on June 8, 2021. 
 
You asked the Plan to waive the cost sharing for the ultrasound guidance, two injections, and the specialist 
visit. You say that you do not think you should have to pay anything for this because the injections did nothing 
for you and the doctor refused to call you back. The Plan denied your request. The Plan says you were charged 
this cost sharing correctly.  The Plan says that for the ultrasound guidance, the allowed amount for this service 
($40.36) is less than your copayment obligation, so you are responsible for the full allowed 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 $75 
copayment for radiological services, 20% coinsurance for Medicare Part B drugs, and a $20 copayment for 
specialist visits.  
 
You have been asked to pay a $75 copayment for the ultrasound guidance, 20% coinsurance for the two 
injections, and a $20 copayment for the specialist visit. The ultrasound guidance falls within the radiological 
services benefit category. The injections fall in the Medicare Part B drug benefit category.  You had this visit 
with a specialist. This means that you have been asked to pay the correct amounts based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. This 
cost sharing applies regardless of your satisfaction with the services received. Therefore, we decided that the 
Plan does not have to waive the cost sharing for the ultrasound guidance, two injections, and the office visit 
you had with a rheumatologist on June 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for computed tomography (CT) of the head or brain (70450) 
provided on June 13, 2021. 
 
You asked the Plan to pay for the CT of the head or brain. You say that you would like reconsideration because 
the member had multiple exams on the same date of service. The Plan denied your request. The Plan says an 
edit exists between CPT code 70450 and 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 computed tomography (CT) of the head or brain (70450) 
provided on June 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Pentamidine solution provided on May 26, 2021. 
 
You asked the Plan to pay for the services provided. You say that documents support this is an active code. The 
Plan denied your request. The Plan says this claim is not eligible for payment. 
 
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 J2545 is Pentamidine isethionate, inhalation solution, 
food and drug administration (FDA)-approved final product, non-compounded, administered through durable 
medical equipment, unit dose form, per 300 mg. 
 
We find that CPT code J2545 is not recognized by OPPS when submitted on an outpatient hospital Part B bill 
type (12x and 13x). 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 Pentamidine 
solution provided on May 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home enteral services rendered on March 10, 2021 to 
March 13, 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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid 
for Medicare purposes.  
 
We looked at the file and Medicare rules. Billed procedure code S9343 (home therapy; enteral nutrition via 
bolus; administrative services, professional pharmacy services, care coordination, and all necessary supplies 
and equipment, per diem) has a status indicator of I and is not valid for Medicare purposes. Therefore, we 
decided that the Plan does not have to pay for the home enteral services rendered on March 10, 2021 to March 
13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on May 10, 
2021. 
 
You asked the Plan to pay for the services. You say that the services are not coronavirus screening testing. 
Molecular genetic screening testing is not a Medicare benefit for the diagnoses as listed on the claim and are 
done for screening purposes. The review has determined that the services at issue in this case were not 
medically reasonable or necessary. The Plan denied your request. The Plan says Medicare says screening 
panels/testing with no relation to a medical diagnosis of disease for the health of the patient are not a benefit. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found [state the medical finding(s) upon which the physician based his/her conclusion] 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services provided to the enrollee on May 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve monitored anesthesia care (MAC) during a facet joint 
injection. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this could be approved if the doctor sent notes explaining why sedation is needed. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the review has determined that this patient does not have a diagnosis, condition, and/or symptoms that 
meet the Medicare criteria for coverage of monitored anesthesia care. There is no significant previous medical 
history to warrant monitored anesthesia care. There is no indication in the clinical documentation as to why the 
request for anesthesia was included. The review has determined that the enrollee does not require 
anesthesiology services for this injection. 

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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve monitored anesthesia care (MAC) during a facet joint injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the retreatment of previous root canal therapy (D3348) 
provided on May 5, 2021. 
 
You asked the Plan to pay for the retreatment of previous root canal therapy. You say that you would like to 
appeal this service. The Plan denied your request. The Plan says this service is not covered under the Plan. 
 
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 
retreatment of previous root canal therapy (D3348) provided on May 5, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says care can be received in another setting, such as home, long-term care facility, or 
other outpatient setting. 
 
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 the admission. Our reviewer says that 
the requested admission is not medically reasonable or necessary. Our physician reviewer found he enrollee 
does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee 
does not have documented skilled therapy needs. The enrollee is ambulating more than 100 feet and tending to 
ADLs with minimal supervision. Daily skilled services are not required to establish a maintenance program or 
to prevent deterioration of the enrollee's condition. The enrollee's care needs can be provided at a lower level 
of 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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services provided on March 12, 2021.
You asked the Plan to pay for the services provided. You say that the medical records support the claim. The Plan denied your request. The Plan says no separate payment is made.
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 99053 is service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service. We find that CPT code 99053 is a bundled code. Payment for them is subsumed by the payment for the services to which they are incident. 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 outpatient hospital services provided on March 12, 2021.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to reduce the cost-sharing charges for phlebotomy services. We decided that the 
Plan does not have to reduce the cost-sharing charges for phlebotomy services to the amount you requested.  
 
You asked the Plan to reduce the cost-sharing charges for phlebotomy services. You say that the blood draw 
should be included with no copayment. The Plan says that the claims were processed correctly and you are 
being charged the correct amount. 
 
We decided that the Plan has to reduce the cost-sharing charges for phlebotomy services from $121.01, 
to $40.  
 
The health Plan contract says that enrollees must pay a $40 copayment for non-radiological diagnostic services.  
 
The Plan says that you must pay $121.01 for phlebotomy services. However, phlebotomy services are 
considered a diagnostic procedure and you cannot be asked to pay more than a $40 copayment. Therefore, we 
decided that the Plan has to reduce the cost-sharing charges for phlebotomy services from $121.01 to $40.  
 
We also decided that the Plan does not have to reduce the cost-sharing charges for phlebotomy services 
to the amount you requested.  
 
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 non-radiological diagnostic services. Therefore, we decided that the Plan does not have to waive 
the $40 copayment for phlebotomy services. 
 
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 lab services provided on April 14, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are 
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 testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab 
services provided on April 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services (99291) provide don December 14, 
2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
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 99291 is "Critical care, evaluation and management of 
the critically ill or critically injured patient; first 30-74 minutes". 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the records do not show that 
30-74 minutes of critical care services were provided on December 14, 2020. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan 
does not have to pay for the critical care services (99291) provide don December 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Adderall XR for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that the member was diagnosed with Narcolepsy with 
cataplexy and that she needs the medication. The Plan denied your request. The Plan says that this is not 
covered under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Adderall XR for the 
enrollee.  
 
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says care can be provided in the current inpatient hospital.
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 improving with current treatment and is more stable. They require only short-term additional acute care hospital services that can safely be administered at the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility. Therefore, this request for LTACH services will be considered not medically necessary as there would be insufficient clinical advantage to transferring. Transfer may be considered soon when the enrollee's treatment has completed and when they are appropriate for treatment at a lower level of 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 admission to a long term acute care hospital (LTACH) for the enrollee.
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that 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 does 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. There is not a 
reasonable expectation that you 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.