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

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 82306, 82607, 82728, 
83036, 83540, 83550, 84153 and 83698-90) provided on June 24, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the records support services billed. The Plan 
denied your request. The Plan says these are screening services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our coder 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 laboratory services. Our reviewer found the review has 
determined that based on the available medical records, the billed codes:  82306, 82607, 82728, 83036, 83540, 
83550, 84153 and 83698-90, are not authorized because screening testing is not a Medicare benefit when done 
without documentation of medical indication from the treating provider. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services (CPT code(s): 82306, 82607, 82728, 83036, 83540, 83550, 
84153 and 83698-90) provided on June 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair accessory, electronic connection 
between wheelchair controller and two or more power seating system motors (E2311). 
 
You asked the Plan to pre-approve a power wheelchair accessory. You say that the enrollee has very poor 
cardiopulmonary function, neurological and musculoskeletal conditions and generalized weakness. The 
requested mobility device will not only maximize her independence but also her overall quality of life. The 
Plan denied your request. The Plan says although there are three approved power options on this wheelchair 
(tilt, recline and elevating leg rests), there is not a medical need to control these power options through the 
joystick. Documentation shows that the enrollee has 5/5 strength in the upper limbs per her physician. 
 
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. There is not a medical need to control these power options through the joystick. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair accessory, electronic connection between wheelchair controller and two or more power seating system motors (E2311).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services (99152) provided on 
November 24, 2021. 
 
You asked the Plan to pay for code 99152. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the records do not support the services 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 99152 is Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the medical record does not 
contain evidence that moderate sedation was performed with the presence of an independent trained observer. 
Based on this information, we decided that Medicare rules for coverage of code 99152 have not been met. 
Therefore, we decided that the Plan does not have to pay for the moderate sedation services (99152) provided 
on November 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the prophylaxis - adult (D1110), bitewings - four 
radiographic images (D0274), and periodic oral evaluation - established patient (D0120) provided January 31, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay more for the dental services. You say that your provider told you they were in-
network. The Plan denied your request. The Plan says you are responsible for any charged amount above the 
Plans cost-sharing amount when your services are received from an out-of-network provider. 
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for the prophylaxis - adult (D1110), bitewings - 
four radiographic images (D0274), and periodic oral evaluation - established patient (D0120) provided January 
31, 2022, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight further home health physical therapy visits. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records support that the enrollee is 
functioning at a level that does not require home health physical therapy. He lives in a supervised setting with 
assistance available at all times. Ongoing home physical therapy services are therefore not reasonable or 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve eight further home health physical therapy visits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36247, 75630, and 75710 billed for date of 
service March 22, 2022. 
 
You asked the Plan to pay for procedure code 36247, 75630, and 75710. You say that you disagree with the 
denial. The Plan denied your request. The Plan says payment for codes 36247, 75630, and 75710 are bundled 
into payment for code 37224. 
 
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 codes 
36247, 75630, and 75710 are column II codes to column I code 37224. 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 36247, 75630, and 75710 
billed for date of service March 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a guided tissue regeneration (D4266), incisional biopsy 
(D7286), a cone beam CT capture (D0367), and an extraction (D7210), provided by an out-of-network provider 
on December 1, 2021, to December 9, 2021. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. 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 Plans 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 guided tissue regeneration (D4266), incisional biopsy (D7286), a cone beam CT capture (D0367), 
and an extraction (D7210), provided by an out-of-network provider on December 1, 2021, to December 9, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you have been bedridden for so long that you will 
need rehabilitation to restore your full strength. The Plan denied your request. The Plan says after the internal 
review it was determined that based on Medicare guidelines, the inpatient rehabilitation facility services you 
are requesting do not meet the requirements for approval. 
 
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 you are already ambulating household distances. Your therapy notes indicate that 
you have decreased endurance and activity tolerance. The complexity of your nursing, medical and 
rehabilitation needs do not require and acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. While you may benefit from additional multiple therapies, including physical and 
occupational therapy, the documentation does not reveal that you can tolerate this therapy on an intensive IRF 
level. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine (90750) and administration (90471) 
provided on April 20, 2022. 
 
You asked the Plan to pay for the vaccine. You say that you were advised you should get the shingles vaccine 
due to your pain. You say that you had foregone this vaccine in the past due to the cost. You also say that you 
were advise that there should not be a cost for this vaccine now. The Plan denied your request. The Plan says 
the shingles vaccine is not covered under Medicare Part B. 
 
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 shingles vaccine (90750) and administration 
(90471) provided on April 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluations (D0140) 
provided on May 11, 2022, and May 18, 2022. 
 
You asked the Plan to pay for the problem focused limited oral evaluations. 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 February 17, 2022. 
Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluations 
(D0140) provided on May 11, 2022, and May 18, 2022.
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 IRF care is medically necessary/ The Plan denied 
your request. The Plan says the member does not meet IRF criteria. 
 
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 the members nursing, medical and rehabilitation needs do not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
member does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. There is not a reasonable expectation that this 
individual will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an inpatient rehabilitation facility. The member continues to have a need for skilled therapy with 
ongoing safety concerns and a potential for functional improvement however, the documentation doesnt 
support that she would meet criteria for admission to an acute inpatient rehabilitation facility.  There is no 
indication that the member would require skilled rehabilitation in an IRF, participating in rehab services 15 
hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain her 
functional status.  The member can receive further services 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), periodontal 
scaling and root planing (D4341), and gingival irrigation (D4921), provided by a participating provider on May 
6, 2022, to May 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you believe the Plan should pay for this. 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 D0150 and D4341 was exhausted on date of service May 19, 2021. D4921 is not a 
covered benefit. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation 
(D0150), periodontal scaling and root planing (D4341), and gingival irrigation (D4921), provided by a 
participating provider on May 6, 2022, to May 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from May 13, 2020, to 
May 16, 2020, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
claim should be paid as billed. The Plan denied your request. The Plan says the principal diagnosis of severe 
protein calorie malnutrition is not supported in the medical records, so the DRG was downgraded 
appropriately. 
 
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 of severe protein calorie 
malnutrition. 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 inpatient hospital services at the 
DRG originally billed. Our reviewer says that the medical records do not support the billing of a principal 
diagnosis of severe protein calorie malnutrition. Our physician reviewer found the enrollee was a then, 67-year-
old male with past medical history of chronic obstructive pulmonary disease, alcohol abuse, and ankle fracture 
with open reduction and internal fixation on April 13, 2020, who presented with cellulitis of left lower 
extremity with exposed ankle hardware and was admitted to the hospital from May 13, 2020, to May 16, 2020. 
The member presented to the emergency room for worsening left ankle pain with full thickness open wound 
with exposed hardware. He was admitted to the hospital for further care. He was seen by Orthopedics and 
underwent a left below the knee amputation. The provider requested payment for DRG 908 (severe protein 
calorie malnutrition). The member had a body mass index (BMI) of 19.56 which is in the normal range, no 
documented edema, and a normal protein of 7.2gm/dl and a normal albumin of 3.5 gm/dl on admission. There 
was no evidence of severe protein calorie malnutrition on admission.  
 
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 hospital services provided from May 13, 2020, to May 16, 2020, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits, electrocardiogram (99203, 99213, 
echocardiography, transthoracic (93000), real-time with image documentation (93306), myocardial strain 
imaging (93356), positron emission tomography (PET) (78492), cardiovascular stress test (93015), rubidium 
rb-82 (A9555), and regadenoson (J2785) provided on April 1, 2022, to May 13, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the physician services. You say that your primary doctor referred you to the 
provider in this case. You also say that you were never advised this provider was not in your network or that 
you needed approval for these tests. The Plan denied your request. The Plan says services received out-of-
network are not covered. 
 
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 provider in this case is not a network provider with the Plan. The record does not indicate that there was a 
referring provider for the services you received. The Plan did not pre-approve the services at issue. We found 
no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not 
have to pay for the office visits, electrocardiogram (99203, 99213, echocardiography, transthoracic (93000), 
real-time with image documentation (93306), myocardial strain imaging (93356), positron emission 
tomography (PET) (78492), cardiovascular stress test (93015), rubidium rb-82 (A9555), and regadenoson 
(J2785) provided on April 1, 2022, to May 13, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an inpatient hospital stay provided on 
April 22, 2022, to April 23, 2022. 
 
You asked the Plan to reduce the copayment for an inpatient hospital stay. You say that this is too much for 
you to pay 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 $200 
copayment for inpatient hospital care. 
 
You have been asked to pay a $200 copayment for an inpatient hospital stay. 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 reduce the copayment for an inpatient hospital stay 
provided on April 22, 2022, to April 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care services provided on August 
26, 2021. 
 
You asked the Plan to waive the copayment for urgent care services. You say that you should not be 
responsible to pay 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 $45 
copayment for Urgently Needed Services. 
 
You have been asked to pay a $45 copayment for urgent care services. This item/service falls within the 
Urgently Needed Services 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 urgent care services provided on 
August 26, 2021.