Persius/hicric huggingface dataset:
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 the enrollee needs to be transferred to an 
LTACH to regain maximum level of functioning and needs a continued multi-disciplinary approach to care. 
The Plan denied your request. The Plan says the enrollee does not have clinical conditions that cannot be 
appropriately treated in the current hospital, and there are no issues for which LTACH may offer a therapeutic 
advantage. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving with current treatment but is still somewhat unstable and requires additional acute care services that can safely be provided at the current facility until more 
stable and appropriate for transfer. The enrollee does not require services at the LTACH that are not already 
available at the current facility. There are no services at the LTACH that the enrollee requires that are not 
already available and covered at the current facility. Transfer to the LTACH is not medically necessary as the 
enrollee is not yet stable for transfer and as it would not be clinically advantageous. Completion of treatment at 
the current facility is recommended. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the excision of a benign lesion up to 1.25 cm (D7410) 
provided on July 19, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not covered under the 
supplemental dental policy.  
 
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, the service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the excision of a 
benign lesion up to 1.25 cm (D7410) provided on July 19, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (procedure 99285) provided 
on July 6, 2023. 
 
You asked the Plan to pay for an emergency department visit (procedure 99285). You say that procedure code 
99285 is appropriate based on the services performed. The Plan denied your request. The Plan says the records 
do not support the services at issue in this case. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
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 an emergency department visit (procedure 99285). Our 
reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer 
found that the documentation supports an appropriate history and physical exam was performed; However, 
records do not support a high level of complexity or medical decision making. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an emergency department visit (procedure 99285) have not been met. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit (procedure 99285) 
provided on July 6, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous transcatheter closure of the left atrial 
appendage with endocardial implant (LAAC) (33340) and a transesophageal echocardiogram (TEE) (93355). 
 
You asked the Plan to pre-approve an LAAC and TEE. You say that this is medically necessary. The Plan 
denied your request. The Plan says records do not show that the enrollee is unable to take long-term 
anticoagulation. The request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules say that LAAC is covered when specific criteria are met, such as if 
the enrollee is unable to take oral anticoagulants. 
 
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 an LAAC and TEE. 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 apparent contraindication to anticoagulation. As such, guidelines would 
not support implantation of a LAAC in this 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 an LAAC and TEE have not been met. Therefore, we decided that the Plan does 
not have to pre-approve percutaneous transcatheter closure of the left atrial appendage with endocardial 
implant (LAAC) (33340) and a transesophageal echocardiogram (TEE) (93355).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 13, 2023. 
 
You asked the Plan to pay for an office visit. You say that the services rendered were medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on October 13, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic (SPECT) 
(78452). 
 
You asked the Plan to pre-approve a SPECT test. You say that this is medically necessary. The Plan denied 
your request. The Plan says your records do not show you have symptoms of coronary artery disease (damage 
to vessels that supply the heart and limit blood flow) like fainting (syncope) and abnormal heart rhythm. 
 
The Plan follows Medicare rules. Medicare rules say that Myocardial Perfusion Imaging will be considered 
medically reasonable and necessary for specific indications. 
 
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 SPECT test. Our reviewer says that 
there is insufficient documentation to support the medical necessity for the requested cardiac stress testing in 
your clinical management. Our physician reviewer found there is no documentation that the electrocardiogram 
shows an uninterpretable pattern. There is no evidence provided that would support the need for radionuclide 
stress testing. 
 
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 SPECT test have not been met. Therefore, we decided that the Plan does not 
have to pre-approve myocardial perfusion imaging, tomographic (SPECT) (78452).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided from January 10, 2022, to 
August 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that because of your cancer you experienced 
significant oral health problems. Proper dental care is an important component of your overall cancer treatment 
and recover plan. The Plan denied your request. The Plan says these services are not covered benefits under 
your Medicare plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the dental services provided from 
January 10, 2022, to August 17, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy. provided on August 28, 2023. 
 
You asked the Plan to pay for physical therapy.. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for physical therapy. 
provided on August 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for out-of-network outpatient diagnostic tests 
and out-of-network outpatient surgeries provided on April 30, 2023, to May 1, 2023. 
 
You asked the Plan to waive the cost share for outpatient diagnostic tests and outpatient surgeries. You say that 
you disagree with the cost share. 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 a $500 deductible and a 40% coinsurance which applies to out-of-
network outpatient diagnostic tests and out-of-network outpatient surgery.  
 
The item or service you asked the Plan to waive the cost share for falls within the out-of-network outpatient 
diagnostic tests and out-of-network outpatient surgery benefit category. You are being asked to pay $327.07 
towards your deductible. The total amount you are being asked to pay towards your coinsurance is $2,780.50 
($6,951.25 x 40% = $2,780.50). The Plan has followed Medicare rules by clearly disclosing in the contract that 
there is a $500 deductible and a 40% coinsurance which applies to out-of-network outpatient diagnostic tests and out-of-network outpatient surgery. This cost sharing is a contractual obligation that had not been met at the 
time outpatient diagnostic tests and outpatient surgeries was received on April 30, 2023 to May 1, 2023. 
Therefore, we decided that the Plan does not have to waive the cost share for out-of-network outpatient 
diagnostic tests and out-of-network outpatient surgeries provided on April 30, 2023, to May 1, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance treatment without transport provided on May 18, 
2023. 
 
You asked the Plan to pay for the ambulance treatment without transport. You say that you were not 
transported to the hospital and should not owe this money. The Plan denied your request. The Plan says the 
Medicare ambulance benefit is a transportation benefit and without a transport there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 18, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance treatment without transport provided 
on May 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on August 10, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for OON services. You say that the documentation supports medical necessity. The 
Plan denied your request. The Plan says an active Medicaid number was not submitted. 
 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 Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these OON services. Therefore, we decided that 
the Plan does not have to pay for the office visit provided on August 10, 2023, by an out-of-network (OON) 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crowns (D2740 x 5) and core buildups (D2950 x 5) 
provided on May 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you needed these dental services and hope the 
Plan can make an exception and provide additional dental coverage. 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 May 23, 2022. Therefore, 
we decided that the Plan does not have to pay for the crowns (D2740 x 5) and core buildups (D2950 x 5) 
provided on May 23, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cataract surgery and supplies provided on April 25, 2023. 
 You asked the Plan to pay for the cataract surgery and supplies. You say that the services were medically 
necessary. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on April 2, 2023. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the cataract surgery and 
supplies provided on April 25, 2023.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 00320-AA-P4. We decided 
that the Plan does not have to pay for the services described by procedure code(s) 99100.  
 
You asked the Plan to pay for practitioner services provided on July 19, 2023, billed with procedure codes 
00320-AA-P4 and 99100. You say that the claim is billed correctly and should be paid. The Plan says that code 
99100 is considered bundled and is not separately payable. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 00320-AA-P4.  
 
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 did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported. Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 00320-AA-P4.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
99100. 
 
The Plan follows Medicare rules. Medicare rules say that the Physician Fee Schedule Status Indicator B means 
that payment for covered services is always bundled into payment for other services not specified.  
 
We looked at the file, and Medicare rules. We have confirmed that code 99100 has a status indicator B and is 
not separately payable. Based on this information, we decided that Medicare rules for coverage of the services 
described by procedure code(s) 99100 have not been met. Therefore, we decided that the Plan does not have to 
pay for the services described by procedure code(s) 99100. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implanted loop recorder (ILR). 
 You asked the Plan to pre-approve the requested ILR procedure. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say ILR placement may be considered medically 
necessary when it is needed to evaluate syncope that is thought to be cardiac-related but occurs too infrequently 
to be detected by traditional external monitors.  
 
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 requested ILR procedure. Our 
reviewer says that the requested ILR procedure is not medically reasonable and necessary based on NCD 
criteria. Our physician reviewer found while the patient has a history of atrial fibrillation, there is no 
documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent 
indication for an ILR. 
 
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 requested ILR procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of an implanted loop recorder (ILR).
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 without LTACH services the enrollee's 
ability to regain maximum function could be seriously jeopardized. The Plan denied your request. The Plan 
says when the enrollee is ready to leave the hospital they can receive this care in another setting, such as skilled 
nursing facility (SNF). 
 
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 still be unstable and requires additional acute care services 
that can safely be provided at the current facility until more stable and appropriate for transfer. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no 
services at the LTACH that the patient requires that are not already available and covered at the current facility. 
Transfer to the LTACH is not medically necessary as the enrollee is not yet stable and as it would not be 
clinically advantageous. Completion of treatment at the current facility is recommended. 
 
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.