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

 
We decided that the Plan does not have to pay for lab services provided on February 2, 2021. 
 
You asked the Plan to pay for the lab services. You say that the claim should be reviewed and reprocessed. 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 provided on February 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
  You asked the Plan to pre-approve facet joint injections. The Plan denied your request. The Plan says the 
enrollee does not meet the criteria to qualify for coverage. 
 
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 facet joint injections. Our reviewer says 
that the requested service is not medically necessary in this case. Our physician reviewer found that the 
enrollee has radicular signs and symptoms; therefore, the request is not reasonable and 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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided 
from April 18, 2022, to April 21, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that the Plan has denied 
the medical services saying you were admitted to the hospital with belly and chest pain. You also say that this 
is an incorrect diagnosis as to your admission to the hospital. The Plan denied your request. The Plan says this 
claim processed and paid 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 $90 
copayment for Emergency care.  
 
 
 
 
 You have been asked to pay a $90 copayment for the inpatient hospital services. The inpatient hospital services 
you received fall within the Emergency 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 the inpatient hospital services provided from April 18, 2022, to April 21, 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 a genicular nerve block. You say that this procedure is medically reasonable 
and necessary. The Plan denied your request. The Plan says the requested procedure is considered 
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 a genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is a 73-year-old man who had a right total knee arthroplasty in 2014. 
They had a revision surgery on October 27, 2021. They have continuing severe pain post procedure. The 
requested genicular nerve block procedure is considered experimental/investigational for post-total knee 
replacement pain. Therefore, the request is deemed 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 a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and acellular pertussis vaccine 
(Tdap) (90715) provided on July 16, 2021. 
 
You asked the Plan to pay for the vaccine. You say that your doctor ordered this vaccine for prevention due to 
your weakening immune system post-transplant. You say that you were not told you should have gotten this 
done at a pharmacy. You also say you should not be responsible for this bill. The Plan denied your request. The 
Plan says the claim processed correctly. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine. 
Therefore, we decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and acellular 
pertussis vaccine (Tdap) (90715) provided on July 16, 2021.  
 
Benefits for the vaccine 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on May 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that your dental visit was an emergency, and you 
were in pain. 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 4, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
May 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reinstate the benefit for a comprehensive evaluation (D0150) 
provided on April 20, 2022. 
 
You asked the Plan to reinstate the benefit for the dental services. You say that you did not receive the 
comprehensive evaluation on April 20, 2022. You say that because the Plan incorrectly paid for it, your benefit 
was exhausted when you had it done with a different provider. The Plan denied your request. The Plan says the 
evaluation was performed on April 20, 2022, and the claim has processed correctly. 
 
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, certain limitations apply. The medical 
records show you did have a comprehensive evaluation on April 20, 2022. The Plan paid for the service, which 
exhausted your benefit for the next 6 months. Therefore, we decided that the Plan does not have to reinstate the 
benefit for a comprehensive evaluation (D0150) provided on April 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service May 12, 
2022. 
 
You asked the Plan to pay for procedure code 71045. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 71045 is bundled into payment for code 36573. 
 
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 71045 
is a column II code to column I code 36573. 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 71045 billed for date of service May 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection. 
 
You asked the Plan to pre-approve SI joint injection. You say that this is medically necessary. The Plan denied 
your request. The Plan says the request for these SI joint injections is not supported by at least 3 provocative 
tests. 
 
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 SI joint injection. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation of 3 provocative tests (such as Yeoman's, Faber, 
Gaenslan's, thigh thrust, or SI joint compression) that support the diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SI joint injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a sacroiliac (SI) joint injection.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service April 5, 
2022. 
 
You asked the Plan to pay for procedure code 70544. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 70544 is bundled into payment for code 70551. 
 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 70544 
is a column II code to column I code 70551. 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 70544 billed for date of service April 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3010) provided on December 9, 2021. 
 
You asked the Plan to pre-approve foot orthotics. You say that the requested items are a medical necessity for 
you. The Plan denied your request. The Plan says these items are not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3010) provided on 
December 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on March 16, 2022, by a 
chiropractor. 
 
You asked the Plan to pay for the chiropractic care. You say that you say that the office advised they needed 
$100 to put down. You say that chiropractic care has a $20 copayment. The Plan denied your request. The Plan 
says the claim processed correctly. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99202) provided on March 16, 2022, by a chiropractor.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that it is medically necessary for you to receive SNF 
care. The Plan denied your request. The Plan says the records received do not support the enrollee's needs for 
daily skilled services in a SNF. The records received show that the enrollee can safely go to a different setting 
to receive therapy less than daily to maintain their function. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that there are no identifiable skilled nursing service needs. There are identifiable 
skilled therapy service needs. The enrollee does not require skilled nursing or therapy services daily basis. This 
enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gastrointestinal tract imaging. 
 You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
request does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that capsule endoscopies are only covered under 
certain medical indications.  
 
We looked at the file and Medicare rules. The file shows that the enrollee received an upper gastrointestinal 
endoscopy on September 1, 2022, with normal results. There is no indication the endoscopy failed to identify a 
bleeding source. Based on this information, we decided that Medicare rules for coverage of the requested 
services have not been met. Therefore, we decided that the Plan does not have to pre-approve a gastrointestinal 
tract imaging.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs 15 liters of oxygen, and a lower 
level of care facility is not going to be able to supervise carefully. The Plan denied your request. The Plan says 
that that the 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that the clinical documentation clearly shows that the enrollee will continue to require close medical 
monitoring on an inpatient basis. Evaluating physical and occupational therapists specifically state that the 
enrollee would tolerate three hours of therapy daily and requires intense therapy. In this case, the IRF criteria 
has been met and is medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
IRF admission and 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service May 7, 2022. 
 
You asked the Plan to pay for procedure code 76700. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 76700 is bundled into payment for code 93976. 
 
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 76700 
is a column II code to column I code 93976. 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 76700 billed for date of service May 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from October 7, 2021, through 
October 11, 2021, at DRG 871. 
 
You asked the Plan to pay for inpatient services at DRG 871. You say that principal diagnosis code A41.52 is 
supported by the physician's documentation and the information in the medical record. You say that the 
documentation supports the DRG as billed, and you disagree with the DRG reassignment. The Plan denied 
your request. The Plan says principal diagnosis code A41.52 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code A41.52, defined as sepsis 
due to Pseudomonas. 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 inpatient services at DRG 
871. Our reviewer says that the documentation does not support principal diagnosis code A41.52 because the 
clinical validation criteria is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient services provided from October 7, 2021, through October 11, 2021, at DRG 871.
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 currently meets LTAC 
admission under Medicare guidelines. The Plan denied your request. The Plan says admission to LTACH was 
denied as not meeting criteria, is not medically necessary, and continued acute hospital stay was offered, until 
the enrollee could discharge to a lower level of care. 
 
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 improving and should only require short 
term additional acute care hospital services that can safely be administered at the current facility until more 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility. 
 
 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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services (87640, 87581, 87486, 87541) provided on April 
19, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and are supported 
in the medical record. The Plan denied your request. The Plan says that these services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Local Coverage Determination cited by the Plan was retired and 
no longer valid before the date in question. The Plan has provided no other reason for denial or supporting 
citation for their denial in this case. Therefore, we decided that the Plan has to pay for laboratory services 
(87640, 87581, 87486, 87541) provided on April 19, 2022.  
 
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.