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

We decided that the Plan does not have to pay for a limited oral evaluation (D0140), an intraoral periapical radiographic image (D0220 x2), a single bitewing radiographic image (D0270 x2), and an extraction (D7140) provided from June 9, 2022, through June 22, 2022, by an out-of-network provider.

You asked the Plan to pay for the dental services. You say that you were not aware that you had to use an in-network provider. The Plan denied your request. The Plan says the dental services were received from an out-of-network provider and are not covered by your supplemental benefits.

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 record shows you received the requested dental services from an out-of-network provider. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), an intraoral periapical radiographic image (D0220 x2), a single bitewing radiographic image (D0270 x2), and an extraction (D7140) provided from June 9, 2022, through June 22, 2022, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of torus mandibularis (D7473) Tooth #Q30 and 
therapeutic parenteral drugs, two or more administrations, different meds (D9612). 
 
You asked the Plan to pre-approve the dental services. You say that you need the requested services so you can 
get false teeth, in order to be able to eat. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. 
  
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. This benefit includes the 
requested removal of torus mandibularis (D7473) but is limited to one (D7473) every calendar year. 
Therapeutic parenteral drugs, two or more administrations, different meds (D9612) is not covered under the 
Plan's dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested removal of torus mandibularis (D7473) Tooth #Q40 was approved on the 
original request, therefore this benefit has been exhausted. Therefore, we decided that the Plan does not have to 
pre-approve removal of torus mandibularis (D7473) Tooth #Q30 and therapeutic parenteral drugs, two or more 
administrations, different meds (D9612).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Level IV - Surgical pathology, gross and microscopic 
examination (88305) provided July 27, 2022. 
 
You asked the Plan to pay for the cytology testing. You say that please review the attached medical report and 
reconsider the denied charge for payment. The Plan denied your request. The Plan says this claim is a duplicate 
of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed.  

We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on September 13, 2022. Comparison of the two claims shows these are exact 
duplicates. There is no evidence presented to support that the billed items/services were provided twice on the 
same date. Based on this information, we decided that the Medicare rules for the cytology testing have not been 
met. Therefore, we decided that the Plan does not have to pay for Level IV - Surgical pathology, gross and 
microscopic examination (88305) provided July 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care (99291) provided on August 3, 2022. 
 
You asked the Plan to pay for critical care. You say that this service is supported in the medical records. The 
Plan denied your request. The Plan says this service is not supported 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 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 time spent providing this 
care is not noted in the medical record. Without this information, a time-based code such as 99291 cannot be 
verified. Based on this information, we decided that Medicare rules for coverage of critical care have not been met. Therefore, we decided that the Plan does not have to pay for critical care (99291) provided on August 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a Coflex interspinous device (22867, 
C1821). 
 
You asked the Plan to pre-approve placement of a Coflex interspinous device. You say that the requested 
service is a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested 
service is experimental/investigational. 
 
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 placement of a Coflex interspinous 
device. Our reviewer says that the requested service is not considered medically reasonable and necessary in 
this case. Our physician reviewer found that the Coflex device is experimental. More research is needed to 
demonstrate its safety and effectiveness.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of placement of a Coflex interspinous device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve placement of a Coflex interspinous device (22867, C1821).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service October 10, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service October 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81292) provided on June 5, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and appropriate. 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, for 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 (81292) provided on June 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service July 16, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that these services are separately payable. The 
Plan denied your request. The Plan says procedure code 99100 is considered bundled and not separately 
payable. 

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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service July 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically necessary. The Plan denied your request. The Plan says that the admission to a LTACH is not medically necessary.

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. 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 LTACH services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four home health physical therapy visits. 
 You asked the Plan to pre-approve home health visits. The Plan denied your request. The Plan says the services 
are not medically necessary. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
provided records do not document any acute or unstable medical conditions or injuries which would necessitate 
any further skilled therapy visits beyond what have already been approved. The records document that you 
have been educated on your medical condition and a home exercise 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve four home health physical therapy visits.
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 an LTACH is the appropriate level of care the enrollee. The Plan denied your request. The Plan says the enrollee's needs are being met in the current setting.

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 physician reviewer found that the enrollee was admitted to the acute care hospital with acute necrotizing pancreatitis. The enrollee appears to be more stable and improving with current treatment. The enrollee should only require short-term additional acute care services that can safely be provided at the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility. Transfer to the LTACH is not medically necessary as it would not be clinically advantageous 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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Keytruda (CPT code J9271). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says that the use of Keyturda for Stage IVB Malignant neoplasm of rectum (C20) and 
metastatic colon cancer is not FDA approved or listed in the Medicare-approved sources. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 medication. Our physician reviewer 
found based on tumor mutational burden (TMB) high, treatment of unresectable or metastatic tumor mutational 
burden-high solid tumors (TMB-H; greater than or equal to 10 mutations/megabase [mut/Mb]; as determined 
by an approved test) in adult and pediatric patients who have progressed following prior treatment and have no 
satisfactory alternative treatment options. The documentation supports that the requested drug is safe and 
effective and otherwise reasonable and necessary for this enrollee. 
 
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 medication have been met. Therefore, we decided that the Plan has to pre-
approve Keytruda (CPT code J9271).  
 
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the medical eye exam (92014) provided on August 22, 2022.

You asked the Plan to waive the deductible for the medical eye exam. You say that you feel that you should not be charged any amount because this was a preventive exam for diabetes. You also say that you have never been charged before, and do not understand why you are being charged now. The Plan denied your request. The Plan says this cost sharing was charged correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is an $800 deductible which applies to Vision care.

The service you asked the Plan to waive the deductible for falls within the Vision care benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is an $800 deductible which applies to Vision care. This cost sharing is a contractual obligation that had not been met at the time the medical eye exam was received on August 22, 2022. Therefore, we decided that the Plan does not have to waive the deductible for the medical eye exam (92014) provided on August 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital care associated with an 
approved elective reverse total left shoulder arthroplasty (23472). 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that an inpatient stay is medically 
necessary. The Plan denied your request. The Plan says there is no documentation provided to support the 
expectation that you 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 pre-approve 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 detailed documentation is not evident regarding a significant past 
and/or current medical history that would place you at increased risk for peri-surgical complications requiring 
an inpatient stay. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the record does not show that at the time of 
inpatient admission, the admitting physician would reasonably expect that your necessary hospital care will 
span two midnights. 
 
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 pre-approve the acute inpatient hospital care associated with an approved elective reverse 
total left shoulder arthroplasty (23472).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service October 14, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the patient had multiple procedures on this 
date of service. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service October 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided on September 29, 
2022. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you would like the Plan to pay for 
this. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed 
amount is $454.26. The total amount you are being asked to pay is $90.85 ($454.26 x 20% = $90.85). This 
item/service falls within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the coinsurance for an injection provided on September 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and one power seating system motor (E2310). 
 
You asked the Plan to pre-approve a wheelchair accessory. You say that the wheelchair and accessories are 
medically necessary for the enrollee. The Plan denied your request. The Plan says the enhanced electronic 
connection exceeds the enrollee's needs and is not reasonable and necessary, per Medicare criteria. 

 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 patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that although there is an approved power option on this wheelchair (tilt), there is not a medical 
need to control this power option through the joystick. The member's documented functional right upper limb 
abilities are adequate for the member to be able to control the tilt power option using its own switch which is 
included in the allowance of the power option. This means that Medicare rules for coverage of a wheelchair 
accessory have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic 
connection between wheelchair controller and one power seating system motor (E2310).