Persius/hicric huggingface dataset:
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 enrollee needs IRF care. The Plan denied your 
request. The Plan says The enrollee does not meet the requirements 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: 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 enrollee would benefit from his care. The Plan 
denied your request. The Plan says the enrollee's condition does 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 enrollee does not require complex or intensive rehabilitation and does not require 
frequent psychiatry oversight.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 occupational therapy visits. 
 
You asked the Plan to pre-approve 6 occupational therapy visits. You say that you would like to request 
reconsideration of the denied home health services and that the services requested are medically necessary. The 
Plan denied your request. The Plan says the services are not medically necessary.  
 
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 clinical 
documentation does not specify any unmet home health OT goals and documentation reports that patient was to 
be discharged from home health OT, thus the records do not show that additional home health OT visits are 
required to effectively provide treatment. 
 
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 6 occupational therapy visits.
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 requesting reconsideration of denied 
authorization. The Plan denied your request. The Plan says the coverage criteria has not been met  
 
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 do 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. Medically necessary care can be provided in a different level of 
care. There is no reasonable expectation that this enrollee will be able to fully participate in and benefit from 
the intensive rehabilitation therapy program provided in an IRF.  
 
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: Favorable

 
We decided that the Plan has to pay for procedure code 99347 provided on April 7, 2023, and April 21, 2023. 
 
You asked the Plan to pay for procedure code 99347. 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 as billed. 
 
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. We find that Per Medicare coding guidelines, procedure code 99347 can be 
billed with place of service code 55. The Plan has not provided any Medicare rules or regulations to support 
that the place of service billed is not payable with procedure code 99347. Additionally, the Plan has not 
provided any evidence per Medicare criteria that diagnosis codes L70.9 and B19.20 cannot be billed with place 
of service 55. Therefore, we decided that the Plan has to pay for procedure code 99347 provided on April 7, 
2023, and April 21, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0220), and bitewings (D0270) provided 
on August 14, 2023. 
 
You asked the Plan to pay for the dental services. You say that this provider was in-network. 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 February 7, 2023. Therefore, we decided that the Plan does not have to pay for intraoral imaging (D0220), and bitewings (D0270) 
provided on August 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a retainer crown (D6740), and pontics (D6245) provided on 
February 27, 2023. 
 
You asked the Plan to pay for D6740 and D6245. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the denied dental services are not covered benefits. 
 
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 a retainer 
crown (D6740), and pontics (D6245) provided on February 27, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for post-stabilization care provided from March 3, 2023, after 
10:01 to March 9, 2023. 
 
You asked the Plan to pay for post-stabilization care. You say that  in the physician's professional judgement, 
the enrollee required an inpatient admission. The Plan denied your request. The Plan says the enrollee's 
emergency medical condition stabilized by March 3, 2023, and subsequent care was post-stabilization care, not 
approved in compliance with the health plan's authorization procedures. The Plan also says that the Plan has 
paid for all emergent care up to the point of stability. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 post-stabilization care. Our physician 
reviewer found there's documentation of the enrollee being unstable for transfer. The documentation on March 
2, 2023, describe the enrollee as requiring 5L/m oxygen support via nasal cannula but not requiring bilevel 
positive airway pressure (BiPAP), however, was "not stable for transfer." However, the documentation 
suggested that on March 3, 2023, the enrollee was tolerating 4L/m (low dose) oxygen support with otherwise 
stable vitals, no acute distress, and improving with treatment. The enrollee appeared stable enough for transfer. Therefore, the post-stabilization care provided is not supported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of post-stabilization care have not been met. Therefore, we decided that the Plan 
does not have to pay for post-stabilization care provided from March 3, 2023, after 10:01 to March 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A4208, A4649, 96374, and 96375 billed for 
date of service April 30, 2023. 
 
You asked the Plan to pay for the billed services. You say that additional payment should be made. The Plan 
denied your request. The Plan says the billed codes 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 code. 
 
We find that codes 96374 and 96375 have a PC/TC indicator of 5. This means that payment may not be made 
for these services when they are provided to hospital inpatients or patients in a hospital outpatient department. 
The claim was billed with place of service code 23, a hospital emergency room.  
 
We find that code A4208 has a status indicator of X. This means that no payment amounts are shown for these 
codes and no payment may be made under the physician fee schedule. Code A4649 has a status indicator of P. 
This means that payment for it is bundled into the payment for the physician service to which it is incident. 
 
We looked at the file and the rules. Based on this information, we decided that Medicare rules for coverage of 
the billed services have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
codes A4208, A4649, 96374, and 96375 billed for date of service April 30, 2023.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure codes U0004 and U0005. We decided that the Plan does not 
have to pay for procedure codes 87486, 87541, 87581, 87631, and 87798.  
 
You asked the Plan to pay for the lab testing billed for date of service April 3, 2023. The Plan says that one 
code must be submitted for the panel. 
 
We decided that the Plan has to pay for procedure codes U0004 and U0005.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
The CPT Code Manual definition of code U0004 is 2019-NCOV Coronavirus, SARS-COV-2/2019-NCOV 
(Covid-19), any technique, multiple types or subtypes (includes all targets), non-CDC, making use of high 
throughput technologies as described by CMS-2020-01-R. 
 
The CPT Code Manual definition of code U0005 is infectious agent detection by nucleic acid; severe acute 
respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), amplified probe technique, 
making use of high throughput technologies, completed within 2 calendar days from date of specimen 
collection (list separately in addition to either code U0003 or U0004) as described by CMS-2020-01-R2. 
 
We find that Covid-19 testing, billed with code U0004, was provided. The testing was completed within 2 
calendar days from the date of specimen collection, which makes code U0005 applicable. Based on this 
information, we decided that the Medicare rules for coverage have been met. Therefore, we decided that the 
Plan has to pay for procedure codes U0004 and U0005 billed for date of service April 3, 2023.  
 
We also decided that the Plan does not have to pay for procedure codes 87486, 87541, 87581, 87631, and 
87798. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
The file shows that a respiratory panel test was provided. We looked at the file and Medicare rules. This NGS 
panel was not billed with a single code as required. Based on this information, we decided that Medicare rules 
for coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
87486, 87541, 87581, 87631, and 87798 billed for date of service April 3, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330), the guided tissue 
regeneration (D4266), the surgical placement of implant body (D6011), and the surgical access to implant body 
(D6011) for tooth #4 provided on March 17, 2023, and April 19, 2023. 
 
You asked the Plan to pay for the dental services. You say that the visit was for a consultation and not an 
evaluation and you were told multiple times that the bone graft would be covered. The Plan denied your 
request. The Plan says your benefit for the panoramic radiographic image has already been exhausted. Also, the 
guided tissue regeneration, the surgical placement of implant body, and the surgical access to implant body are 
not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid for a panoramic radiographic image (D0330) on April 13, 2021; therefore, your benefit for 
the panoramic radiographic image was exhausted on the  date of service of April 13, 2021. The guided tissue 
regeneration, the surgical placement of implant body, and the surgical access to implant body are not covered 
under the Plan's dental benefit. Therefore, we decided that the Plan does not have to pay for the panoramic 
radiographic image (D0330), the guided tissue regeneration (D4266), the surgical placement of implant body 
(D6011), and the surgical access to implant body (D6011) for tooth #4 provided on March 17, 2023, and April 
19, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ER services provided on July 24, 2023, to 
July 25, 2023. 
 
You asked the Plan to waive the copayment for ER services. You say that this 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 $100 
copayment for emergency care.  
 
You have been asked to pay $100 copayment for ER services. This item/service falls within the emergency 
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. Therefore, we decided that the Plan does not have to waive the copayment for ER services provided on July 24, 
2023, to July 25, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 87493 and 87481 billed for date of service June 21, 
2023. 
 
You asked the Plan to pay for procedure codes 87493 and 87481. You say that you have billed the services at 
issue correctly. The Plan denied your request. The Plan says that the provided records do not support the 
services billed. 
 
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 87493 is: Infectious agent detection by nucleic acid 
(DNA or RNA); Clostridium difficile, toxin gene(s), amplified probe technique. 
 
The definition of code 87481 is: Infectious agent detection by nucleic acid (DNA or RNA); Candida species, 
amplified probe technique. 
 
We find that CPT codes 87493 and 87481 are supported in the medical record. Specifically, the provided 
medical records document that testing was performed for Clostridium difficile and for Candida species. Based 
on this information, we decided that Medicare rules for coverage of procedure codes 87493 and 87481 have 
been met. Therefore, we decided that the Plan has to pay for procedure codes 87493 and 87481 billed for date 
of service June 21, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the odontoplasty-per tooth (D9971) and the 
unspecified periodontal procedure, by report (D4999) provided on April 7, 2023 and April 18, 2023. 
 
You asked the Plan to issue reimbursement 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 services 
provided are not covered under the supplemental dental policy.  
  
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to issue reimbursement for 
the odontoplasty-per tooth (D9971) and the unspecified periodontal procedure, by report (D4999) provided on 
April 7, 2023 and April 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes E0951-NURTKX, E0951-NULTKX, and 
E2611-NUKX provided on June 9, 2023. 
 
You asked the Plan to pay for procedure codes E0951 and E2611. You say that you would like the Plan to 
reconsider their denial of payment. 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 for procedure code E0951 or proof of delivery for 
procedure code E2611. 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 procedure codes 
E0951-NURTKX, E0951-NULTKX, and E2611-NUKX provided on June 9, 2023.