Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 28, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the service was provided by an out-of-network 
provider. 
 
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 practitioner services provided on April 28, 2023, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99233) provided from March 13, 2023, to 
March 15, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
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 find that CPT code 99233 is not supported in the medical record. Specifically, the records provided do not 
contain any identifiable information showing that the services were provided to the enrollee in this case. As 
such, it cannot be verified that the billed services were provided. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (99233) provided from March 13, 2023, to March 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cancer screening and an office visit provided on August 
10, 2023. 
 
You asked the Plan to pay for the cancer screening and an office visit. You say that you are requesting 
reconsideration of the denied claim. 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 the cancer screening and 
an office visit provided on August 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bed side rails, full length (E0310). 
 
You asked the Plan to pre-approve the bed rails. You say that you are appealing the denial for bed rails for the 
enrollee due to several falls from their bed while sleeping. The Plan denied your request. The Plan says only 
the preferred brand products listed in the EOC are covered.   
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for the bed rails. Therefore, we decided that the Plan does not have to pre-approve the bed side rails, full length 
(E0310).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (11900, J3301) provided on June 1, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the service at issue was 
not billed with the required modifier to allow separate payment within the global surgery period. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM 
services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue (11900) is within the global surgery period of 
code 66984 provided on April 4, 2023. We find that the service at issue may be unrelated to the surgical 
procedure; however, the required modifier to indicate this was not used. As such, the billing rules for these 
services have not been met. 
 
Medicare rules also say that submitted claims in which the unit of service exceeds the MUE value cannot be 
paid when the MAI value is 3, unless there is evidence justifying the excess units.  
 
In this case, the MUE for CPT code J3301 is 16. The MAI value for this code is 3. You billed 40 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code J3301 have not been met. Therefore, we decided that the 
Plan does not have to pay for the services (11900, J3301) provided on June 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatments provided from March 30, 2023, 
to April 21, 2023. 
 
You asked the Plan to pay for the acupuncture services. You say that you are entitled to twenty acupuncture 
visits. The Plan denied your request. The Plan says acupuncture is only covered when furnished by the 
appropriate credentialed physician. 
 
  The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the submitted documentation does not indicate the 
specific practitioner that performed the services at issue and whether they are a licensed practitioner of 
acupuncture. Therefore, we decided that the Plan does not have to pay for the acupuncture treatments provided 
from March 30, 2023, to April 21, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sigmoidoscopy and the injection provided on June 28, 
2022. 
 
You asked the Plan to pay for the sigmoidoscopy and the injection. You say that you are requesting 
reconsideration of the denied claim. 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 the sigmoidoscopy and 
the injection provided on June 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist telemedicine visit provided on 
July 12, 2023. 
 
You asked the Plan to waive the copayment for specialist telemedicine visit. You say that you disagree with the 
copayment. 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 physician/practitioner services/specialist telemedicine visit. 
 
You have been asked to pay a $45 copayment for specialist telemedicine visit. This item/service falls within the 
physician/practitioner services/specialist telemedicine visit 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 specialist telemedicine visit provided on July 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hospital outpatient clinic visit to be provided by an 
out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the outpatient service. You say that you were told that you were advised by 
a Plan representative that you could have surgery here because you had been a patient there for eight years. 
You say that you are now finding out it was not approved. The Plan denied your request. The Plan says the 
service can be provided in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a hospital outpatient clinic visit to be provided by an out-of-network (OON) provider.   
 
Your complaint about being misled by a Plan representative is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20245 rendered on June 12, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 20245-59 remains not supported. 
 
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 20245 is "Biopsy, bone, open; deep (eg, humeral shaft, 
ischium, femoral shaft)." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the enrollee was being treated for 
pain in the right hip and displaced subtrochanteric fracture of the right femur. She underwent an open reduction and internal fixation, right subtrochanteric femur fracture; fluoroscopic interpretation for placement of 
hardware; intramedullary reamings and bone biopsy, deep, sent for pathology on 6/11/23.  
The procedure details cite the fracture was noted to be unreduced with muscle and was incarcerated. The 
fracture was then gently reduced utilizing traction. A long ball-tipped guidewire was placed down through the 
intramedullary canal. While the fracture was held reduced, reaming commended up to 12mm. An 11 x 360 x 
125 degree nail was placed over the guidewire and the guidewire was removed through the previous flexor 
incision site. A 95mm lag screw was gently drilled and reamed and subsequently placed with compression 
carried out. The noted bone biopsy was performed in part of the noted open reduction internal fixation of the 
fracture. Therefore, the documentation does not support CPT 20245: biopsy, bone, open; deep (e.g., humeral 
shaft, ischium, femoral shaft) as a separate and distinct procedure from CPT 27245: treatment of 
intertrochanteric, peri-trochanteric, or subtrochanteric femoral fracture; with intramedullary implant, with or 
without interlocking screws and/or cerclage. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 20245 rendered on June 12, 2023.
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 admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says admission to an IRF does not meet 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 that based on the medical records provided the complexity of the patient's nursing, 
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollee's medical conditions appear stable on outpatient medications with 
no issues that appear to require a physician's evaluation three or more times per week in a hospital setting. The 
enrollee does require physical therapy and occupational therapy services, but the medical records provided do 
not clarify that the patient requires the medical oversight of an intensive inpatient rehabilitation therapy 
program. The enrollee would be expected to participate in and benefit from the intensive rehabilitation therapy 
program provided in an inpatient rehabilitation facility, however the medical records do not support a 
complexity of medical and rehabilitation needs to require an acute inpatient rehabilitation facility over a skilled 
nursing 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 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: 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 you are a fall risk and require IRF services. The Plan 
denied your request. The Plan says the request is not medically necessary.  
 
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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 crown (D2740) for tooth #11, the core buildup (D2950) for 
tooth #8, #9, #11, a pontic (D6245) for tooth #10, and a retainer crown (D6740) for tooth #6, #9, and #11. 
 
You asked the Plan to pay for the dental services. You say that the enrollee needs to replace their anterior 
bridge. The Plan denied your request. The Plan says the denial of authorization for these services is correct, 
because they did not meet the criteria for coverage. 
 
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 the dental 
services 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 pay for the dental services. Our reviewer says that 
the crown (D2740) for tooth #11, the core buildup (D2950) for tooth #8, #9, #11, a pontic (D6245) for tooth 
#10, and a retainer crown (D6740) for tooth #6, #9, and #11 is not medically necessary or necessary due to the 
poor prognosis of these teeth. Our physician reviewer found that the x-rays show severe bone loss, with a poor 
crown to root ratio. The office manager also stated that the teeth have mobility, and it is not the standard of care 
to place bridges on teeth with mobility. A crown is also not recommended for tooth #11 due to the severe bone 
loss. The bridge will fail and does not have a good long-term prognosis. 
 
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 the dental services have not been met. Therefore, we decided that the Plan does 
not have to pay for a crown (D2740) for tooth #11, the core buildup (D2950) for tooth #8, #9, #11, a pontic 
(D6245) for tooth #10, and a retainer crown (D6740) for tooth #6, #9, and #11.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 95939-TC, 95938-TC, 95927-TC, 95861-
TC, 95937-TC, and 95940 billed for date of service May 22, 2023. 
 
You asked the Plan to pay for procedure code(s) 95939-TC, 95938-TC, 95927-TC, 95861-TC, 95937-TC, and 
95940. You say that the claim is billed correctly and should be paid. 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 this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 95939-TC, 95938-TC, 
95927-TC, 95861-TC, 95937-TC, and 95940. 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) 95939-TC, 95938-TC, 95927-TC, 95861-TC, 95937-TC, and 95940. Based on this 
information, we decided that Medicare rules for coverage of procedure code 95939-TC, 95938-TC, 95927-TC, 
95861-TC, 95937-TC, and 95940 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code(s) 95939-TC, 95938-TC, 95927-TC, 95861-TC, 95937-TC, and 95940 billed for date of 
service May 22, 2023.
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 necessary. The Plan denied your request. 
The Plan says IRF care is not reasonable and necessary.  
 
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 enrollees nursing, medical, and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee 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 the enrollee 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
inpatient rehabilitation facility. The medical records do not support that the enrollee would meet criteria for 
admission to an acute inpatient rehabilitation facility. The enrollee 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.