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

 
We decided that the Plan does not have to waive the cost sharing for the initial comprehensive preventive 
medicine evaluation, and the cervical or vaginal cancer screening provided by an out-of-network provider on 
July 12, 2023. 
 
You asked the Plan to waive the cost sharing for the preventive medicine evaluation and the cancer screening. 
You say that these services should be covered. 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% 
coinsurance for out-of-network annual wellness visits, and out-of-network Medicare-covered preventive pap 
and pelvic exams. 
 
You have been asked to pay a $61.25 coinsurance for the preventive medicine evaluation ($153.13 allowed 
amount x .40 = $61.25). This item/service falls within the annual wellness visit benefit category. You have also 
been asked to pay a $15.11 coinsurance for the cancer screening ($37.77 allowed amount x .40 = $15.11 
rounded up). This item/service falls within the cervical and vaginal cancer screening 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 cost sharing for the initial comprehensive preventive medicine evaluation, 
and the cervical or vaginal cancer screening provided by an out-of-network provider on July 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral hygiene instructions (D1330), and periodontal 
maintenance (D4910) provided on July 21, 2023. 
 
You asked the Plan to pay for the dental services. You say that you don't understand how you have met your 
annual maximum for the year. The Plan denied your request. The Plan says your benefit for the requested item 
or service $2,000 dollar limit was met. 
 
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 services was exhausted on date of service April 7, 2023. Therefore, we 
decided that the Plan does not have to pay for the oral hygiene instructions (D1330), and periodontal 
maintenance (D4910) provided on July 21, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from March 8, 
2023, through March 9, 2023. 
 
 
  
 
 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient hospital care provided was 
not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee was evaluated and treated with intravenous Lasix, oral blood pressure 
medication (Coreg), as well as fluids, Norco, Tylenol, and appropriate home medications. She was admitted 
and her echocardiogram showed normal heart function, and the computed tomography (CT) scan of the head 
and chest did not show any acute changes. She responded well to treatment and was discharged the following 
day on March 9, 2023. The review has determined that the record did not show that at the time of the inpatient 
admission it was reasonable for the admitting physician to expect that the enrollees necessary hospital care 
(including earlier emergency department (ED) and/or observation care) would span two midnights with 
supporting documentation of the enrollees history and comorbidities, signs and symptoms, current medical 
needs, and risk of an adverse event. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient hospital care provided from March 8, 2023, through March 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) system, supply 
allowance, and accessories (A4239) provided on June 25, 2023. 
 
You asked the Plan to pay for the CGM, supply allowance, and accessories. You say that the medical records 
provided support the need for the requested services rendered. The Plan denied your request. The Plan says the 
records do not indicate that the member had sufficient training using the CGM prescribed or that a referral was 
sent to the provider for a CGM or supplies. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee has not had an in-
person visit with their treating physician to evaluate their diabetes control and to determine whether the criteria 
for coverage have been met. Based on this information, we decided that Medicare rules for coverage of the 
CGM, supply allowance, and accessories have not been met. Therefore, we decided that the Plan does not have 
to pay for the continuous glucose monitor (CGM) system, supply allowance, and accessories (A4239) provided 
on June 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the full cost for the chiropractic manipulative treatment 
(98941) and the extra spinal chiropractic manipulative treatment (98943) provided on July 17, 2023. 
 
  You asked the Plan to pay for the full cost for the chiropractic manipulative treatment (98941) and the extra 
spinal chiropractic manipulative treatment (98943). You say that you have back problems, related to age and 
overuse which resulted in a trip to the emergency room a year ago. You say that you thought you had kidney 
stone, but it turned out to be a misalignment of your spine, and the muscles over-compensating for the 
alignment. The Plan denied your request. The Plan says the chiropractic manipulative treatment was processed 
correctly with a $20 copayment and the extra spinal chiropractic manipulative treatment is not covered as the 
only covered chiropractic service is manual manipulation of the spine. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
You have been asked to pay a $20 for the chiropractic manipulative treatment (98941). This item/service falls 
within the Chiropractic Services benefit category. In addition, the extra spinal chiropractic manipulative 
treatment (98943) remains denied as it is not a covered chiropractic service. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does 
not have to pay for the full cost for the chiropractic manipulative treatment (98941) and the extra spinal 
chiropractic manipulative treatment (98943) provided on July 17, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on January 31, 2023, to 
February 24, 2023.  
 You asked the Plan to pay for home health services. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the plan of care was signed after the date(s) of service in question; 
therefore, the plan of care is not valid. 
 
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 looked at the file, and Medicare rules. The plan of care was signed after the date(s) of service in question. 
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 pay for the home health services provided on January 
31, 2023, to February 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthosis provided by an out-of-network provider on June 
16, 2023. 
 
You asked the Plan to pay for the orthosis. You say that you are appealing the denied claims. The Plan denied 
your request. The Plan says the documentation requirements have not been met. 
 The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid physician order. Specifically, the physician order was dated June 24, 2023, 
which was after the date of delivery of June 16, 2023. The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for the orthosis provided by an out-of-network provider on June 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for local anesthesia in conjunction with operative or surgical 
procedures (D9215) provided on July 18, 2023. 
 
You asked the Plan to pay for local anesthesia in conjunction with operative or surgical procedures. 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 local 
anesthesia in conjunction with operative or surgical procedures (D9215) provided on July 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pain specialty provider visit provided on July 17, 2023. 
 
You asked the Plan to pay for a specialist visit. You say that you had met the deductible for this year already 
and should not owe any money for this visit. 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 $150 deductible which applies to physician/practitioner services, 
including doctors office visits. You had not reached the deductible amount at the time of this service. You 
have been asked to pay $123.54 towards the 2023 deductible. 
 
The item or service you asked the Plan to pay for falls within the physician/practitioner services, including 
doctors office visits benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $150 deductible which applies to physician/practitioner services, including doctors 
office visits.  This cost sharing is a contractual obligation that had not been met at the time a specialist visit was received on 
July 17, 2023. Therefore, we decided that the Plan does not have to pay for a pain specialty provider visit 
provided on July 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 you would like IRF services as you are unable to 
walk after pelvic surgery. The Plan denied your request. The Plan says you do not meet the criteria for an IRF 
admission.  
 
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 does not 
require an acute 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, and 
an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation program provided in an IRF. 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 procedure code 99100 billed for date of service July 19, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that you are requesting the claim be reviewed 
and reprocessed for payment. The Plan denied your request. The Plan says procedure code 99100 is considered 
bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service July 19, 2023.
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 an LTACH is the appropriate level of 
care for the enrollee. You say that the enrollee is medically stable to be transferred to LTACH level of care. 
The Plan denied your request. The Plan says an LTACH admission is not medically necessary.  
 
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 is improving and only requires short-term acute care at the current 
facility until they are more stable. The enrollee does not require services at the LTACH that are not already 
available at the current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH 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 would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee does not require the intensity of services 
provided at an IRF. The enrollee may require physical and occupational therapies to improve their ability to 
ambulate and perform activities of daily living. However, those needs can be met at a lower 
level of care, such as a skilled nursing facility (SNF).  
 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 enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. 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 IRF. 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 pre-approve facet joint injections. 
 
You asked the Plan to pre-approve the injections. The Plan denied your request. The Plan says facet joint 
injections are not medically necessary.  
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 the injections. Our reviewer says that 
facet joint injections are not medically necessary. Our physician reviewer found that there is documentation of 
radiculopathy. Therefore, the enrollee does not meet the LCD coverage criteria. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint injections.
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 is unable to stay in hospital 
and requires continued services. The Plan denied your request. The Plan says the records do not show that the 
enrollee needs treatments that can only be given in a hospital. 
 
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 and should only require 
short-term additional acute care services that can safely be provided at the current facility and soon transfer to a 
lower level of care. The enrollee does not require services at the LTACH that are not already available at the 
current facility. 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 long term acute care hospital (LTACH) services.