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

 
We decided that the Plan does not have to pay for the laboratory services (0240U) provided on December 31, 
2022. 
 
You asked the Plan to pay for procedure code 0240U. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the claim for this molecular pathology testing 
did not include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of procedure code 0240U 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
(0240U) provided on December 31, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on November 9, 2022. 
 
You asked the Plan to pay for the laboratory services. 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. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-
of-network with the Plan. The documentation submitted does not include prior notice from the Plan that these 
tests would not be covered. Without this information, we cannot determine whether the lab order made 
constituted plan-directed care. Therefore, we decided that the Plan has to pay for the laboratory services 
provided on November 9, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary for the enrollee. The Plan
denied your request. The Plan says that a lower level of care might be appropriate.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for IRF care. Our
Medical Director states that the available documentation does not support that the complexity of the enrollee's
nursing, medical and rehabilitation needs required an acute hospital inpatient stay with an interdisciplinary
approach to rehabilitation care.
Our Medical Director found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires close medical 
monitoring, and daily physician oversight. You say that the enrollee is stable to be transferred to a LTACH 
which will give them the best positive outcome. The Plan denied your request. The Plan says an LTACH 
admission is not medically necessary, and the enrollee can safely receive the care they need in another 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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where the enrollee is currently receiving care. The health plan has approved ongoing care in 
the current acute care setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the abatacept injections provided on 
September 23, 2022, and October 21, 2022. 
 
You asked the Plan to waive the coinsurance for the drug injections. You say that you had already met your 
out-of-pocket maximum. 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 20% 
coinsurance for Medicare Part B drugs.  The records show you had not met your out-of-pocket maximum before the drug injection services were 
provided on September 23, 2022, and October 21, 2022. You have been asked to pay 20% coinsurance for each 
drug injection. These items/services fall within the Medicare Part B drugs benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the coinsurance for the abatacept injections provided on September 23, 2022, and 
October 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for guided tissue regeneration, natural teeth resorbable 
barrier, per site (D4266), bone replacement graft for ridge preservation - per site (D7953), consultation - 
diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310), 
therapeutic parenteral drugs, two or more administrations, different medications (D9612), extraction, erupted 
tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if 
indicated (D7210) and deep sedation/general anesthesia first 15-minutes (D9222) provided on May 5, 2022. 
 
You asked the Plan to pay more for dental services. You say that you disagree with the denial of payment for 
the services you received. The Plan denied your request. The Plan says these services are not covered under 
your Plan. 
 
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. Enrollees must pay 20% to 
50% coinsurance and a $50 deductible for covered in-network dental services. This benefit includes only those 
items and services specifically listed in your Plan contract. Guided tissue regeneration, natural teeth resorbable 
barrier, per site (D4266), bone replacement graft for ridge preservation - per site (D7953) and consultation - 
diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310) are not 
covered under the Plans dental benefits. 
 
You have been asked to pay $67.60 for D7210, which is less than the standard $77.60 cost share ($138 allowed 
x 20% coinsurance = 27.60 + $50 deductible = $77.60). You have been asked to pay $65.50 for D9222 ($131 
allowed x 50% coinsurance = $65.50). 
 
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 extraction, erupted tooth requiring removal of bone and/or 
sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) and deep 
sedation/general anesthesia first 15-minutes (D9222) provided on May 5, 2022. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, codes D4266, D7953 and D9310 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
guided tissue regeneration, natural teeth resorbable barrier, per site (D4266), bone replacement graft for ridge 
preservation - per site (D7953) and consultation - diagnostic service provided by dentist or physician other than 
requesting dentist or physician (D9310) provided on May 5, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 9 additional physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy visits. You say that the enrollee would like reconsideration 
because the services are medically necessary. The Plan denied your request. The Plan says 9 additional 
physical therapy visits are not medically necessary. 
 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 physical therapy visits. 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 that the enrollee has an effective therapy program and can 
continue repetitive exercise with a home exercise program. Continued input from a skilled therapist is 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 physical therapy visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 9 additional physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for full mouth debridement (D4355) provided on January 17, 
2023. 
 
You asked the Plan to pay for full mouth debridement. You say that this should be covered. The Plan denied 
your request. The Plan says this is not a covered service. 
 
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 full 
mouth debridement (D4355) provided on January 17, 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 the services are medically necessary for the enrollee, 
and they are very motivated to return to their base line and independent living. The Plan denied your request. 
The Plan says the enrollee does not meet criteria for admission to an acute rehabilitation facility because they 
do not require full time access to a doctor or any specialized equipment. 
 
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 enrollee does not require treatment by multiple therapies. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan provided to the enrollee on May 5, 2022.
You asked the Plan to pay for the CT scan. You say that medical records submitted support the services billed. 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 enrollees who are registered hospital inpatients, the inpatient or outpatient hospital POS code would be reported regardless of where the face-to-face service takes place. POS code 21 is used to describe an inpatient hospital. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Specifically, this claim was not billed with the inpatient hospital POS code. The records support that the enrollee was an inpatient in the hospital on the date of service the CT scan was provided. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan provided to the enrollee on May 5, 2022.
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 the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says an IRF admission 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 the enrollees 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services provided on 
November 17, 2022. 
 
You asked the Plan to waive the copayment for the lab services. You say that these labs were a part of your 
annual physical exam. 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 $40 
copayment for in-network lab services provided at an outpatient hospital.  The lab services are outside the scope of the annual physical exam, and the copayment has been applied 
correctly. You have been asked to pay a $40 copayment for the lab services. These items/services fall within 
the outpatient diagnostic tests and therapeutic 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 the laboratory services provided on November 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation (D0140) provided on December 22, 
2022. 
 
You asked the Plan to pay for limited oral evaluation. You say that this should be covered. The Plan denied 
your request. The Plan says this is not a covered service. 
 
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 limited 
oral evaluation (D0140) provided on December 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary partial denture (D5225). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. 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 January 26, 2022. 
Therefore, we decided that the Plan does not have to pre-approve maxillary partial denture (D5225).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, and 88360 billed for date of 
service April 22, 2022. 
 You asked the Plan to pay for procedure code(s) 88341, 88342, and 88360. You say that you would like the 
Plan to reconsider their denial of payment. The Plan denied your request. The Plan says these codes are 
included in the facility payment and are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, and 
88360. 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) 88341, 
88342, and 88360. Based on this information, we decided that Medicare rules for coverage of procedure codes 
88341, 88342, and 88360 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code(s) 88341, 88342, and 88360 billed for date of service April 22, 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 the services are necessary for you to regain your 
maximum level of function after your surgery. The Plan denied your request. The Plan says you can safely 
receive the services you need in another setting such as a skilled nursing facility, home with home health 
services or home with outpatient therapy. 
 
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 do not require treatment by multiple therapies. 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after May 
1, 2023 
 You asked the Plan to pre-approve SNF care after May 1, 2023. You say that the continued admission to a SNF 
is medically necessary. The Plan denied your request. The Plan says the continued admission to a SNF is not 
medically necessary. 
 
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 after May 1, 2023. 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 after May 1, 2023 have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continued skilled nursing facility (SNF) care after May 1, 2023