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

We decided that the Plan does not have to pay for the acupuncture services provided on August 18, 2020. 
 
You asked the Plan to pay for the acupuncture services. You say that the enrollee has acupuncture benefits for 
chronic pain. The Plan denied your request. The Plan says the provider is not a physician, or being supervised 
by a physician. 
 
The Plan must follow Medicare rules. The rules say that or services provided on or after January 21, 2020, 
Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements. 
However, your Plan offers coverage beyond the Medicare acupuncture benefit.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the services were not provided by a qualified 
physician. Therefore, we decided that the Plan does not have to pay for the acupuncture services provided on 
August 18, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monovisc injection (J7327). 
 
You asked the Plan to pre-approve Monovisc. You say that this service is medically necessary. The Plan denied 
your request. The Plan says this service has been denied under the Medicare Part B benefit because the record 
shows that this drug will be supplied by a pharmacy. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Monovisc injection (J7327).  
 
Benefits for Monovisc may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PureWick system. 
 
You asked the Plan to pre-approve a PureWick system. You say that this is medically necessary. The Plan 
denied your request. The Plan says that this is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that use of the appropriate HCPCS code assures that 
accurate processing can be accomplished resulting in a proper claim determination and reimbursement. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the PureWick system is not met. Specifically, the PDAC code assigned to the PureWick System is 
a non-covered code per Medicare. Therefore, we decided that the Plan does not have to pre-approve a 
PureWick system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the comprehensive oral evaluation (D0150) and 
prophylaxis (D1110) provided on July 9, 2020. 
 
You asked the Plan to pay more for the dental services. You say that you were advised by a plan representative 
that the provider in this case was in network. You also say that you do not see why the plan cannot pay for the 
dental services after you were advised that the provider was in network. The Plan denied your request. The 
Plan says the provider in this case is out of network. The Plan says that there is a 50% coinsurance for dental 
services that you receive out of network. 
 
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, dental services that you receive out of 
network have a 50% coinsurance. The Evidence of Coverage states that you may be billed by the out of 
network provider for any amount greater than the payment made by the Plan to the provider. The record shows 
that the Plan paid the 50% coinsurance for the services that you received. The record shows that the plan 
representative advised you of your out of network benefits. Therefore, we decided that the Plan does not have 
to pay more for the comprehensive oral evaluation (D0150) and prophylaxis (D1110) provided on July 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for biopsy or excision of lymph nodes (38525) intraoperative 
identification of sentinel lymph node(s), includes injection of non-radioactive dye, when performed (list 
separately in addition to code for primary procedure) (38900) mastectomy, partial (19301) provided July 30, 
2020. 
 
You asked the Plan to pay for the surgical procedure. You say that both the primary surgeon and the facility are 
in-network and that CPT  38900 is payable to the assistant surgeon. You are requesting the assistant surgeon's 
claim to be processed in-network. The Plan denied your request. The Plan says the procedure requested does 
not require an assistant at surgery. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. Medicare rules say that providers must report services correctly. Providers must 
report services with the appropriate CPT code. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. 38900 is designated as an add on code and cannot be paid as billed. This code cannot be paid as a 
separate line item. Therefore, we decided that the Plan does not have to pay for biopsy or excision of lymph 
nodes (38525) intraoperative identification of sentinel lymph node(s), includes injection of non-radioactive 
dye, when performed (list separately in addition to code for primary procedure) (38900) mastectomy, partial 
(19301) provided July 30, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the thorax (71250). 
 
You asked the Plan to pre-approve a CT scan of the thorax. You say that the service is medically necessary. 
The Plan denied your request. The Plan says that the member does not meet the guidelines provided for 
coverage of a CT of the thorax and, therefore, the service is not reasonable or necessary. 
 
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 a CT scan of the thorax. Our reviewer 
says that the service is medically necessary. Our physician reviewer found the requirement of a chest X-Ray 
within the last sixty days prior to a CT scan is not indicated for this particular patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CT scan of the thorax have been met. Specifically, a CT of the thorax is 
reasonable and necessary for this patient.  Therefore, we decided that the Plan has to pre-approve a computed 
tomography (CT) scan of the thorax (71250).  
 
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 specialized intraocular lens (IOL) you received on 
October 20, 2020. 
 
You asked the Plan to pay for the lens. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan does not covered specialized intraocular lenses. 
 
We looked at the file and the Plan's rules. The Plan only covers a conventional IOL implanted during cataract 
surgery. Specialist IOLs are not covered by Medicare or your plan.  Based on this information, we decided that 
the Plan's rules for coverage of the lens have not been met. Therefore, we decided that the Plan does not have to 
pay for the specialized intraocular lens (IOL) you received on October 20, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health aide (HHA) visit provided on June 5, 2020. 
 
You asked the Plan to pay for the HHA visit. You say that this should be paid. The Plan denied your request. 
The Plan says this was not billed on the correct claim form. 
 
The Plan must follow Medicare rules. Medicare rules say that home health services must be billed on an 
institutional claim by a home health agency. 
 
This was billed on a professional claim under the NPI of a Physician Assistant (PA). However, the billed code 
was for the services of an HHA, not the PA. As such, this must be billed as an institutional claim by a home 
health agency. Therefore, we decided that the Plan does not have to pay for the home health aide (HHA) visit 
provided on June 5, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided on September 29, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan 
denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring 
provider is also out-of-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 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 lab work provided on September 29, 2020 by an 
out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve partial upper and lower dentures. 
 
You asked the Plan to pre-approve partial upper and lower dentures. You say that you are having trouble eating 
because you current dentures do not fit. The Plan denied your request. The Plan says that this benefit is 
exhausted. 
 
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. The Plan covers one set of 
dentures (partial, full, immediate) every five (5) years.  
 
We looked at the file and Medicare rules. The file indicates you received partial upper and lower dentures on 
September 13, 2016, which is less than five years ago. Based on this information, we decided that the Plan's 
rules for coverage of partial upper and lower dentures have not been met. Therefore, we decided that the Plan 
does not have to pre-approve partial upper and lower dentures.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation provided on June 30, 2020. 
 
You asked the Plan to pay for the limited oral evaluation. You say that another visit was filed in error. You say 
that you have no information on the date in this matter. The Plan denied your request. The Plan says you have 
received this service three times this year. 
 
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, you also have a maximum benefit of 
one emergency diagnostic exam every year. The Plan paid for an emergent diagnostic exam on February 27, 
2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the limited 
oral evaluation provided on June 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Amlodipine/Benazepril 5-20 mg capsule. 
 
You asked the Plan to pre-approve Amlodipine/Benazepril. You say that this service is medically necessary. 
The Plan denied your request. The Plan says This medication does not fall under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Amlodipine/Benazepril 5-
20 mg capsule.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that your needs can be safely met at 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 above. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for a subdural hematoma after a 
fall. Your medical conditions are stable. There are no medical needs requiring inpatient admission. There are 
no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record documents a need for physical and occupational therapy, it does not document a need for an intensive 
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found 
that your 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement (11046) provided on August 17, 2020. 
 
You asked the Plan to pay for debridement. You say that this is supported by the records. The Plan denied your 
request. The Plan says this procedure is not documented. 
 
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 11046 is debridement, muscle and/or fascia (includes 
epidermis, dermis, and subcutaneous tissue, if performed); each additional 20 sq cm, or part thereof (List 
separately in addition to code for primary procedure). 
 
We find that CPT code 11046 is not supported in the medical record. Specifically, the submitted medical 
records do not include documentation of an additional 20 sq cm of debridement. Based on this information, we 
decided that Medicare rules for coverage of debridement have not been met. Therefore, we decided that the 
Plan does not have to pay for debridement (11046) provided on August 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a blood glucose monitor with an integrated voice synthesizer 
provided to the enrollee from August 16, 2020, to November 3, 2020. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documented sufficient visual impairment to require a voice monitor. 
 
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 pay for the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no evidence that the enrollee is visually impaired. As such, the special feature BGM 
and supplies are not shown to have been medically necessary or reasonable. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for a blood glucose monitor with an integrated voice synthesizer provided to the enrollee from 
August 16, 2020, to November 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management services (99238) 
provided on November 14, 2019. 
 
You asked the Plan to pay for the hospital discharge day management services. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation 
does not support the service 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 99238 is hospital discharge day management; 30 minutes 
or less.  
 
We find that CPT code 99238 is not supported in the medical record. Specifically, the documentation does not 
indicate that 30 minutes or less of hospital discharge day management services were rendered on the billed date 
of service. Based on this information, we decided that Medicare rules for coverage of the hospital discharge 
day management services have not been met. Therefore, we decided that the Plan does not have to pay for the 
hospital discharge day management services (99238) provided on November 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power scooter accessories (deluxe contour high back 
seating, rear view mirror, cup holder, lap belt). 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says these accessories 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 lap belt and high back seating. Our 
reviewer says that the requested lap belt and high back seating are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the documentation does not support that these accessories 
are reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of 
a malformed body member. This exceeds your medical need. The treating medical practitioner progress note 
documentation does not support that you have evidence of spasticity, impaired sitting balance, or poor trunk 
control that require a lap belt. The authorized scooter has a seat and a back and the requested high back seating 
exceeds medical need. 
 
Additionally, the rear view mirror are cup holder are convenience items that do not serve a primarily medical 
purpose. 
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve power scooter accessories (deluxe contour high back seating, rear view mirror, cup holder, 
lap belt).
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 you disagree with the denial. The Plan 
denied your request. The Plan says the services are 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 medically necessary. Our physician reviewer found the enrollee was 
admitted to the hospital with acute hemorrhagic stroke and large intraparenchymal hematoma of the right 
parietal lobe and hypertensive emergency treated with intubation, craniotomy, hematoma evacuation, 
tracheostomy, and PEG placement. Recent notes show she is more alert, following simple commands, and 
tolerating weaning. She does not require services at the LTACH that are not already available at the current 
facility. There are no services at the LTACH that the patient requires that is not already available and covered 
at the current facility. The LTACH services are therefore not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the 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.