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

 
We decided that the Plan has to pre-approve a porcelain crown (D2751) for tooth number 8. 
 
You asked the Plan to pre-approve a porcelain crown (D2751) for tooth number 8. You say that your dentist 
filed for pre-authorization for the replacement of a broken crown back in November, and neither of you have 
heard anything since. You also say that you need your dental work done as soon as possible. The Plan denied 
your request. The Plan says that is unable to approve the additional 1 unit of this service as it exceeds the 
frequency for services. 
 
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. The Plan says that this benefit has been exhausted. However, the Plan failed to 
provide verification of the benefit being exhausted. Without the verification, we are unable to prove the 
enrollee did actually exhaust this benefit. Therefore, we decided that the Plan has to pre-approve a porcelain 
crown (D2751) for tooth number 8.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0425, A0428) provided on August 17, 
2022. 
 
You asked the Plan to pay for the ambulance services. You say that this service was medically necessary. 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 20, 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 ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance services (A0425, A0428) 
provided on August 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cervical collar (L0180) provided on August 31, 2022. 
 
You asked the Plan to pay for a cervical collar. You say that the item at issue was a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the information in 
the enrollees medical record adequately supports the medical necessity for the item. 
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The available medical records do not discuss the item at issue. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for a cervical collar (L0180) provided on August 31, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for subsequent hospital inpatient or observation care (99233AI) provided 
on April 4, 2022. 
 
You asked the Plan to pay for the service. You say that this claim is with a provider that specializes in internal 
medicine and it is being denied for a claim for a provider who is with gastroenterology. The Plan denied your 
request. The Plan says that the payment for this service is included in the fee for the procedure. 
 
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. The Plan did not forward another Explanation of Benefits to verify if the other 
claim for the other provider was billed correctly or paid. Therefore, we decided that the Plan has to pay for 
subsequent hospital inpatient or observation care (99233AI) provided on April 4, 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wipes. 
 
You asked the Plan to pre-approve wipes. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested items are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve wipes.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for inpatient hospital care provided on 
October 16, 2022, to October 21, 2022. 
 
You asked the Plan to waive the coinsurance for inpatient hospital care. You say that you feel that MHP should 
continue to extend treatment for COVID-19 with no member cost share because there is still a pandemic. 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 10% 
coinsurance for inpatient hospital care.  
 
The record shows the Plans extension of coverage for COVID-19 treatment at $0 out-of-pocket cost was only 
valid until September 30, 2021. You have been asked to pay a 10% coinsurance for inpatient hospital care. The 
total amount you are being asked to pay for inpatient care is $1,410.16.This item/service falls within the 
inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for inpatient 
hospital care provided on October 16, 2022, to October 21, 2022.  
 
The Rider says that enrollees must pay 10% coinsurance for inpatient hospital services. The Plan contract says 
that if the enrollees group purchases a Rider that amends the coverage and applies a copayment, coinsurance, 
and/or deductible to specific services, the Rider takes precedence over the Evidence of Coverage (EOC) for 
non-preventive services. You can find this information on pages 64 of the Plans 2022 EOC.
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 admission to a Long-Term Acute Care 
Hospital is needed. The Plan denied your request. The Plan says when you are ready to leave the hospital, 
medically necessary care may be provided safely in a different 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 it 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 long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 85060 billed for date of service August 30, 
2022. 
 
You asked the Plan to pay for procedure code(s) 85060. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this code is included in the facility payment and is not separately 
payable.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 8 for CPT code(s) 85060. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 85060. Based on this information, 
we decided that Medicare rules for coverage of procedure code 85060 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 85060 billed for date of service August 30, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotropic testing provided on September 5, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for psychotropic testing. You say that these services were medically necessary. The 
Plan denied your request. The Plan says these services are not covered because they were provided OON 
without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for psychotropic testing provided on September 5, 
2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood smear interpretation and report billed with code 
85060 for August 26, 2022. 
 
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 professional component (PC)/technical component 
(TC) indicator of 8 identifies professional component of clinical laboratory codes for which separate payment 
may be made only if the physician interprets an abnormal smear for hospital inpatient. 
 
We looked at the file and Medicare rules. Billed procedure code 85060 has a PC/TC indicator of 8. The file 
shows that the services were not performed for a hospital inpatient. Therefore, we decided that the Plan does 
not have to pay for the blood smear interpretation and report billed with code 85060 for August 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the water circulating heat pad with pump (E0217) provided 
April 6, 2022, to April 25, 2022. 
 
You asked the Plan to pay for the water circulating heat pad with pump. You say that please reprocess the 
claim. The Plan denied your request. The Plan says this item is covered and not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the water circulating heat pad with pump have not been met. Therefore, we decided that the Plan 
does not have to pay for the water circulating heat pad with pump (E0217) provided April 6, 2022, to April 25, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood smear interpretation and report billed with code 
85060 for August 15, 2022. 
 
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 professional component (PC)/technical component 
(TC) indicator of 8 identifies professional component of clinical laboratory codes for which separate payment 
may be made only if the physician interprets an abnormal smear for hospital inpatient. 
 
We looked at the file and Medicare rules. Billed procedure code 85060 has a PC/TC indicator of 8. The file 
shows that the services were not performed for a hospital inpatient. Therefore, we decided that the Plan does 
not have to pay for the blood smear interpretation and report billed with code 85060 for August 15, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care provided on February 17, 2022. 
 
You asked the Plan to pay for subsequent hospital care. You say that the enrollee was seen by several different 
providers that share the same tax identification number but specialize in different specialties. You say that the 
information should be reviewed, and the claim reprocessed for payment. 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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.   
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for subsequent hospital care provided on February 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee had a very long and 
complicated hospitalization and is strongly recommended for the LTACH admission. The Plan denied your 
request. The Plan says member's needs can be met at 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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. The health 
plan has approved ongoing care in the current acute care 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 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 pre-approve a cap for bridge (D6750) for teeth numbers 28 and 31, 
and a false tooth for bridge (D6240) for teeth numbers 29 and 30. 
 
You asked the Plan to pre-approve a cap for bridge (D6750) for teeth numbers 28 and 31, and a false tooth for 
bridge (D6240) for teeth numbers 29 and 30. You say that you need the bridge because you have a hard time 
eating and it hurts your gums. The Plan denied your request. The Plan says his service is not medically 
necessary. 
 
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. The Plan covers a cap for 
bridge (D6750) for teeth numbers 28 and 31, and a false tooth for bridge (D6240) for teeth numbers 29 and 30 
when the services are medically necessary and reasonable.  
 
 
  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 cap for bridge (D6750) for teeth 
numbers 28 and 31, and a false tooth for bridge (D6240) for teeth numbers 29 and 30. Our reviewer says that 
this is not medically necessary. Our physician reviewer found the documentation does not meet the criteria for 
coverage for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a cap for bridge (D6750) for teeth numbers 28 and 31, and a false tooth for 
bridge (D6240) for teeth numbers 29 and 30 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a cap for bridge (D6750) for teeth numbers 28 and 31, and a false tooth for bridge (D6240) 
for teeth numbers 29 and 30.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for an emergency department visit (code 99285) provided on June 6, 2022. 
 
You asked the Plan to pay for the emergency department visit. You say that the services were medically 
necessary. The Plan denied your request. The Plan says that this charge is incidental to another service. 
 
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 Plan has not provided a Medicare rule, a Plan rule or a coding 
rule to substantiate their denial. Therefore, we decided that the Plan has to pay for an emergency department 
visit (code 99285) provided on June 6, 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99215 billed for date of service November 
17, 2021. 
 
You asked the Plan to pay for procedure code 99215. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 99215 is bundled into payment for code 99205. 
 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 99215 
is a column II code to column I code 99205. 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 99215 billed for date of service November 17, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan 
 
You asked the Plan to pre-approve the CT scan. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they are 
experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found that if there were truly a pulsatile mass on 
physical exam a CTA would ordinarily make sense but the normal carotid ultrasound does not provide a reason 
for further study. 
  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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the CT scan.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT scans provided on June 2, 2022. 
 
You asked the Plan to pay for the CT scans. You say that the services were medically necessary, and you are 
appealing with supporting records. 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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the CT scans provided on June 2, 2022.