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

 
We decided that the Plan does not have to pay for endodontic therapy (D3330) provided on March 17, 2023. 
 
You asked the Plan to pay for D3330. You say that you would like the Plan to pay for this. The Plan denied 
your request. The Plan says the rendered dental service is not a covered benefit. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
endodontic therapy (D3330) provided on March 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing (80307, 83789, G0480) provided on April 26, 
2023. 
 
You asked the Plan to pay for the lab testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed 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 find that CPT codes 80307, 83789, & G0480 are not supported in the medical record. Specifically, the lab 
order provided does not specify which tests are to be performed. The lab order does not specify which tests the 
custom panel ordered consists of. Based on this information, we decided that Medicare rules for coverage of 
the lab testing have not been met. Therefore, we decided that the Plan does not have to pay for lab testing 
(80307, 83789, G0480) provided on April 26, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Direct skilled nursing services of a registered nurse x2. 
 You asked the Plan to pre-approve home health services. You say that .the enrollee is home bound requires use 
walker requiring assistance to leave the home due to weakness and impaired balance. The enrollee also is on 
complex medication regiment that requires oversight from nurse.  The Plan denied your request. The Plan says 
the enrollee's records do not show a need for skilled care that must be performed or supervised by a registered 
nurse 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee 
does not require skilled nursing care for administration of routine medications. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Direct skilled nursing services of a registered nurse x2.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99244 provided on May 18, 2023. 
 
You asked the Plan to pay for procedure code 99244. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for procedure code 99244 by a contract provider. The file does not show that the Plan 
provided notice that procedure code 99244 would not be covered. Under Medicare rules, this means procedure 
code 99244 is considered approved by the Plan. Therefore, we decided that the Plan has to pay for procedure 
code 99244 provided on May 18, 2023.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility provided on May 
01, 2023, to May 18, 2023. 
 
You asked the Plan to waive the copayment for skilled nursing facility. You say that you should not be 
responsible for this 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 
$2052.12 copayment for Skilled nursing facility (SNF) care. 
 
You have been asked to pay a $2052.12 copayment for skilled nursing facility. This item/service falls within 
the Skilled nursing facility (SNF) 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. The amount the provider was billed by the Plan was $7038.68; which the Plans 
share to be paid was $4986.56; leaving with a remaining balance of $2052.12 ($7038.68 - $4986.56 = 
$2052.12). You have not been charged for the day you were discharged. Therefore, we decided that the Plan 
does not have to waive the copayment for skilled nursing facility provided on May 01, 2023, to May 18, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the brain. 
 
You asked the Plan to pre-approve the MRI. You say that the requested MRI is medically necessary. The Plan 
denied your request. The Plan says that the denial of authorization for this service is correct, because the 
enrollee was not diagnosed with dementia. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the 
MRI of the brain is medically necessary. Our physician reviewer found that in this case the enrollee was noted 
to have had a memory impairment. The enrollee was also noted to have a tremor. The performance of an MRI 
of the brain to rule in/out a structural etiology for either condition is within the generally accepted standards of 
practice/care. In such a setting, performance of the requested testing can be considered to be reasonable and 
necessary in order to fulfil part of the evaluation of each condition. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
a magnetic resonance imaging (MRI) of the brain.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code G0482 for date of service June 6, 2023. 
 
You asked the Plan to pay for code G0482. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services billed are 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 G0482 is Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 
drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is not supported in the medical record. Specifically, the documentation shows 
that 15-21 drug classes were not tested. Based on this information, we decided that Medicare rules for coverage 
of code G0482 have not been met. Therefore, we decided that the Plan does not have to pay for code G0482 for 
date of service June 6, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says that the items denied correctly as you do not meet the 
clinical requirements to be approved. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our physician reviewer 
found that the record indicates the enrollee is taking insulin, CGM criteria are met. 
 
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 CGM have been met. Therefore, we decided that the Plan has to pre-
approve a continuous glucose monitor (CGM).  
 
  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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you are currently hospitalized post a second 
emergency surgery on your right knee and not safe to be discharged home. The Plan denied your request. The 
Plan says your records do not show that you need skilled nursing on a daily basis that can only be given in an 
inpatient setting. The Plan says services may be provided home with home health, in residential care, or home 
with close follow-up with your physician. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: 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 it would be good now to transition to a 
LTACH so the enrollee can care for others that have acute needs. The Plan denied your request. The Plan says 
the enrollee can receive this care in the current acute care setting. 
 
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 is receiving appropriate care in current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate at this time. 
 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional occupational therapy (OT) visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the additional OT visits are necessary.  
The Plan denied your request. The Plan says the enrollee does not meet the criteria for additional OT visits.  
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has had 41 sessions of physical therapy and is currently 
performing a home exercise. Their pain is negligible, and the enrollee can perform daily activities with their 
affected extremity. While the enrollee may have some minor deficits with strength and range of motion, further 
progress can be achieved with a home exercise program as their progress has stabilized. Therefore, the 10 
additional OT visits are not 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 the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 10 additional occupational therapy (OT) visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from August 21, 
2022, to October 17, 2022. 
 
  You asked the Plan to pay for the inpatient hospital services. You say that the patient amount was not for admit 
to discharge, and the patient's plan termed. You also say that under the continuation claim should have paid all 
dates of services. The Plan denied your request. The Plan says with the information provided, it cannot be 
determined how the enrollee came to the servicing provider, whether the billed services were actually 
performed, or that the services were medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the inpatient hospital services have 
been met. Medical records were not provided for this case. The record shows that the Plan made multiple 
attempts to obtain this information, but it was not received. Without medical records we are unable to 
determine if the criteria for coverage were met. Therefore, we decided that the Plan does not have to pay for the 
inpatient hospital services provided from August 21, 2022, to October 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0012M for date of service April 7, 2023. 
 
You asked the Plan to pay for procedure code 0012M. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that CxBladder testing identified with code 0012M is 
not covered. 
 
We looked at the file and Medicare rules. The service at issue is specifically not covered. Based on this 
information, we decided that Medicare rules for coverage of procedure code 0012M have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 0012M for date of service April 7, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided on July 17, 2023, billed with 
codes 87150, 87481 and 87798. 
 
You asked the Plan to pay for the laboratory testing billed. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says panel testing should be billed using one CPT code on 
the claim. 
 
The Plan must follow Medicare rules. The rules say that if a laboratory procedure produces multiple reportable 
test results, only a single HCPCS/CPT code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. This was a panel test that was not billed with a single panel code as 
required. Based on this information, we decided that Medicare rules for coverage of the laboratory testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory testing 
provided on July 17, 2023, billed with codes 87150, 87481 and 87798.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 1, 2023. 
 
You asked the Plan to pay for the lab services. You say that you have billed the services at issue correctly. The 
Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on June 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on June 19, 2023. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that the facility requested your 
services and typically handle any authorizations if needed. The Plan denied your request. The Plan says if 
services are received from a non-plan doctor, hospital, or other health care provider without getting approval 
from our Plan, the Plan will not cover the service. The enrollee will have to pay Original Medicare out of 
pocket amounts. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. The services at issue in this appeal were not provided in an emergency or urgent care situation. These services 
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not 
have to pay for subsequent nursing facility care provided on June 19, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the self-administered drug purchased on May 31, 2023. 
 
You asked the Plan to pre-approve the medication. You say that your eye drops were bought a week before 
your surgery, and you were not made aware that it was not covered until two weeks later. You also say that you 
do not have the money to pay this after being told your bill was paid. The Plan denied your request. The Plan 
says the medication is not covered as a medical benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the self-administered drug 
purchased on May 31, 2023.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.