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

 
We decided that the Plan does not have to pay for home health or hospice nursing care provided from July 29, 
2022, to August 27, 2022. 
 You asked the Plan to pay for the nursing care. You say that the NOA was valid from the beginning of the year. 
The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for home health or hospice nursing care provided from July 29, 
2022, to August 27, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the heart. 
 
You asked the Plan to pre-approve the CT scan. You say that the test was ordered by your doctor due to 
concerns regarding high blood pressure and cholesterol. The Plan denied your request. The Plan says that the 
criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CT scan. Our reviewer says that the 
service is medically necessary. Our physician reviewer found CT scans are covered for patients with coronary 
calcium scoring for patients with an atherosclerotic cardiovascular disease (ASCVD) score between 5-
19.9%. You have a score of 6.9% which qualifies for the requested exam. 
 
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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a computed tomography (CT) scan of the heart.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99222-57 provided on February 8, 2023. 
 
You asked the Plan to pay for procedure code 99222-57. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says payment is included in the global surgery 
payment. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery.  
 
We looked at the file and Medicare rules. Payment for procedure code 99222 is included in the global surgery 
payment for procedure code 11721 provided on February 8, 2023. Separate payment cannot be made for 
procedure code 99222. The file shows that the evaluation and management services were provided on the same 
day as a minor surgery that resulted in the initial decision to perform the surgery. This evaluation and 
management service is included in the global surgery payment for the minor surgery and is not separately 
payable. The claim was submitted with procedure code 99222 with modifier -57 incorrectly. Based on this 
information, we decided that Medicare rules for coverage of procedure code 99222 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99222-57 provided on February 8, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve panoramic radiographic image (D0330). 
 
You asked the Plan to pre-approve the dental services. You say that you refused to have your tooth pulled as 
you had already used your $1,000 of dental care for 2022. 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 July 25, 2022. Therefore, 
we decided that the Plan does not have to pre-approve panoramic radiographic image (D0330).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a filling (D2393) provided on March 28, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the charges. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider.  
 
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. 
 
 
  You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 a filling (D2393) provided on March 28, 
2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drug. 
 
You asked the Plan to pay for self-administered drug. 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 pay for self-administered drug.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extraction, erupted tooth (D7210) provided on February 21, 
2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your $500 annual maximum 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. Therefore, we decided that the Plan does 
not have to pay for extraction, erupted tooth (D7210) provided on February 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88305 billed for date of service March 15, 
2023. 
 You asked the Plan to pay for procedure code(s) 88305. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says this code is included in the facility 
payment and is not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that 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) 88305. 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) 88305. Based on this information, 
we decided that Medicare rules for coverage of procedure code 88305 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 88305 billed for date of service March 15, 
2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional skilled nursing facility services. 
 
You asked the Plan to pre-approve additional skilled nursing facility services. You say that you need further 
skilled services to continue to get better. The Plan denied your request. The Plan says skilled SNF days benefit 
has been exhausted. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from February 11, 2023, 
through June 8, 2023. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve additional skilled nursing facility services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a filling (D2393) provided on January 24, 2023 . 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the charges. 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 22, 2023. 
Therefore, we decided that the Plan does not have to pay for a filling (D2393) provided on January 24, 2023
 .
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam (D0364), the pulp vitality tests (D0460), and the 
apicoectomy (D3410) provided on February 24, 2023. 
 
You asked the Plan to pay for the dental services. You say that the dental procedures were medically necessary 
in order to have a cyst removed and you were in significant pain. The Plan denied your request. The Plan says 
the denial of payment for these services is correct, because the cone beam, the pulp vitality tests, and the 
apicoectomy 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 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 cone 
beam (D0364), the pulp vitality tests (D0460), and the apicoectomy (D3410) provided on February 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 44180 and S2900 billed for date of service 
October 31, 2022.  
 
You asked the Plan to pay for procedure codes 44180 and S2900. You say that you would like the Plan to 
reconsider their denial of payment The Plan denied your request. The Plan says payment for code 44180 is 
bundled into payment for code 55821. Additionally, procedure code S2900 is invalid for Medicare purposes. 
 
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, we have confirmed that code 44180 
is a column II code to column I code 55821 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Additionally, we find that 
procedure code S2900 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure 
code S2900 is not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for 
procedure codes 44180 and S2900 billed for date of service October 31, 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 is medically necessary for the enrollee. The Plan 
denied your request. The Plan says the enrollee's records do not show the need for complex rehabilitation 
which would require to be seen three times per week by a rehab doctor for evaluation of functional goals and 
progress. Services needed may be provided safely in a lower level of care. 
 
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. 
 
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 codes 83550, 84443, 82746, 83036, 82607, 83540, 
and 82728 provided on November 19, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide OON care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for procedure codes 83550, 84443, 82746, 83036, 
82607, 83540, and 82728 provided on November 19, 2022, by an out-of-network (OON) provider.
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 your current condition demands immediate intensive 
rehabilitation to regain your independence and restore your quality of life. 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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88305 billed for date of service April 7, 
2022. 
 You asked the Plan to pay for procedure code(s) 88305. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says this code is included in the facility 
payment and is not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that 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) 88305. 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) 88305. Based on this information, 
we decided that Medicare rules for coverage of procedure code 88305 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 88305 billed for date of service April 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services (98940) provided on December 8, 
2022. 
 
You asked the Plan to pay for the chiropractic services (98940). You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the service is not covered as 
billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
We looked at this case file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, the chiropractic services provided in this case are considered maintenance therapy as billed without an AT modifier. Maintenance therapy is not a covered 
benefit under Medicare. The Plan offers supplemental chiropractic services up to 12 visits per year. The file 
shows that the December 8, 2022, visit, was the 13th visit and the Plan had already paid the maximum of 12 
visits for the 2022 benefit year. Therefore, we decided that the Plan does not have to pay for the chiropractic 
services (98940) provided on December 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20930 and 20936 billed for date of service 
March 6, 2023. 
 
You asked the Plan to pay for procedure codes 20930 and 20936. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says procedure codes 20930 and 
20936 are 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 codes 20930 and 20936 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure codes 20930 and 20936 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 20930 and 20936 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 20930 and 20936 billed for date of service 
March 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve accu-chek aviva plus diabetic test strips. 
 
You asked the Plan to pre-approve the test strips. You say that the items should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says only the preferred brand products listed in the 
EOC are covered.  
 
  The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for the test strips. Therefore, we decided that the Plan does not have to pre-approve accu-chek aviva plus 
diabetic test strips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extractions and unspecified maxillofacial prosthesis 
(D7140, D5999).to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent. Services can be provided in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
extractions and unspecified maxillofacial prosthesis (D7140, D5999).to be provided by an out-of-network 
(OON) provider.