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

 
We decided that the Plan does not have to pre-approve out of network providers.  
 
You asked the Plan to pre-approve out of network treatment. You say that you have seen the enrollee since 
2013 and the enrollee prefers to continue treatment with you. The Plan denied your request. The Plan says you 
are not a network provider. 
 
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. You are not a 
network provider with the Plan. The Plan has network providers available who can provide this type of 
treatment. We found no exception that would require the Plan to pre-approve these services. Therefore, we 
decided that the Plan does not have to pre-approve treatment with an out of network provider.
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 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 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 medically necessary. Our physician reviewer found the submitted records show that 
you were admitted to the hospital on December 30, 2020 with fractures of your pubic bone and sacrum. The 
physical therapy note dated January 6, 2021 shows that you need maximum assistance with standing up and 
sitting down. You are able to walk seven feet with a rolled walker and assistance. You do not require the 
intensity of services provided at an IRF. Specifically, you are not shown to be able to tolerate 15 hours per 
week of rehabilitative services with regular physician evaluation. The IRF services are 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on September 
10, 2020. 
 
You asked the Plan to pay for the dental service. You say that you filed an appeal for another claim that was for 
services related to this oral exam. You say that, that claim was paid. You also say that you feel this oral exam 
should be covered because it is related to the paid claim. The Plan denied your request. The Plan says oral 
exams are covered once every 6 months. The Plan says that the frequency limit has been exceeded. 
 
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 frequency limit of 1 oral exam 
every 6 months has been exceeded. The record shows that the Plan paid for an oral exam that you received on 
July 8, 2020, less than 6 months prior. Therefore, we decided that the Plan does not have to pay for the limited 
oral evaluation (D0140) provided on September 10, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram tracing provided on September 15, 
2020. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the service is 
not paid separately. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 93005 is a packaged code in the hospital outpatient prospective payment system. When 
these services are covered, payment for them is subsumed by the payment for the services to which they are 
incident. 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 the electrocardiogram tracing provided on September 15, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 10061) provided on May 3, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot 
be verified. 
 
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 10061 is "Incision and drainage of abscess (e.g., 
carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); 
complicated or multiple". 
 
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 use 
of CPT code 10061 is not supported by the records provided. Our physician reviewer found that the enrollee 
underwent a repeat I&D of a buttock abscess in the ED. This I&D consisted of a single incision to a single 
abscess. No drainage was actually obtained, no wick was placed and no complications were noted. The 
reference to loculations is vague and unsupported by the entirety of the documentation. In the absence of clear 
documentation of a complex abscess or multiple abscesses, the billing of CPT 10061 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (CPT 10061) provided on May 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
March 19, 2020. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you saw the provider but 
feel the provider did nothing for you and you should not be charged. The Plan denied your request. The Plan 
says you have been charged the correct cost sharing amount. 
 
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 $35 
copayment for each specialist visit.  
 
You have been asked to pay a $35 copayment for the specialist office visit. The specialist office visit falls 
within the Physician/Practitioner services, including doctor's office visits benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the specialist office visit provided on March 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services with CPT code 15734 provided on June 
1, 2020. 
 
You asked the Plan to pay for CPT code 15734. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the medical records do not support the billing of CPT 
code 15734. 
 
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 15734 is Muscle, myocutaneous, or fasciocutaneous flap; 
trunk. 
 
We find that CPT code 15734 is not supported in the medical record. Specifically, the operative report did not 
include documentation of a muscle, myocutaneous, or fasciocutaneous flap, obtained from the trunk; therefore, 
this code cannot be verified. Therefore, we decided that the Plan does not have to pay for the surgical services 
with CPT code 15734 provided on June 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network urologist. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says you have been approved to see an in-network tertiary provider. 
 
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 
a referral to an out-of-network urologist.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization 
device (22869, 22870). 
 
You asked the Plan to pre-approve this service. You say that this service is medically necessary as the enrollee 
has lumbar spinal stenosis. The Plan denied your request. The Plan says this service is 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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the device is experimental. More research is needed to show safety and efficacy. Additionally, there 
is no spinal instability indicated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the insertion of a Superion interspinous stabilization device (22869, 22870).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildups, including any pins when required 
(D2950) for tooth number 20 and 31. 
 
You asked the Plan to pre-approve core buildups. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says these items are not a covered benefit under the 
enrollee's 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 requested items are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core 
buildups, including any pins when required (D2950) for tooth number 20 and 31.
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's 
ongoing care needs include tracheostomy care, oxygen supplementation, intravenous antibiotics, surveillance 
laboratory studies, sacral wound care, and therapy services. The documentation does not support that the 
enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is 
currently receiving care. There are no required medical services identified that are available at the LTACH, that 
are not available at the current health care setting being offered by the health plan. Consequently, the requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee at this time. 
 
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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve partial dentures for the enrollee. 
 
You asked the Plan to pre-approve the dentures. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
partial dentures for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Modafinil 200mg tablets for the enrollee. 
 
You asked the Plan to pre-approve Modafinil 200mg tablets. You say that this drug is medically necessary. The 
Plan denied your request. The Plan says this drug is not covered under Medicare 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 Modafinil 200mg tablets for 
the enrollee.  
 
Benefits for Modafinil 200mg tablets 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray services coded 71045 provided on September 28, 
2020. 
 
You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are 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 CPT code. In this case, we have confirmed that code 71045 
for the x-ray services has a bundled relationship with code 32555 and cannot be paid as billed. This code 
cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for the x-ray services coded 71045 provided on 
September 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140) provided on 
June 29, 2020. 
 
You asked the Plan to reimburse you for the dental service. You say that you were advised by your dentist that 
you would be reimbursed by your insurance for the services that you received. You say that you did not think 
that was right. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. 
The Plan also says that services rendered by dentists who have opted out or been excluded from Medicare are 
not eligible for reimbursement. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for 
the limited oral evaluation (D0140) provided on June 29, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for acute inpatient hospital care. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that the services are 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 
services are medically necessary. Our physician reviewer found the enrollee presented to the emergency 
department (ED) reporting weakness and fever. Emergency care included radiology, laboratory, and telemetry 
monitoring. She was diagnosed with a non-ST elevation myocardial infarction and poor healing ankle ulcer. 
The records support a reasonable expectation that the enrollee would require at least two midnights of inpatient 
hospital services. The acute inpatient services are reasonable and 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 these services have been met. Therefore, we decided that the Plan has to pay for 
acute inpatient hospital care.  
 
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: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve six additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that the services are not medically necessary; however, no 
medical records were received for review. Without medical records, a determination based on medical 
necessity cannot be supported. Therefore, we decided that the Plan has to pre-approve six additional physical 
therapy (PT) visits.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered 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 Repatha for the enrollee.  
 
Benefits for this drug 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ninlaro. 
 
You asked the Plan to pre-approve Ninlaro. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee has a medical only policy which does not include Part D prescription 
coverage, therefore the criteria for self-administered drug coverage has not been met. 
 
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 Ninlaro.  
 
Benefits for Ninlaro may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.