Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified preventive procedure (D1999), bitewing x-
rays (D0274), the initial periapical x-ray (D0220), and the additional periapical x-ray (D0230) provided on 
May 13, 2020. 
 
You asked the Plan to pay for the dental services. You say that it has been over 1 year since you have had 
dental services. You also say that you do not understand why the x-rays are not covered. The Plan denied your 
request. The Plan says the unspecified preventive procedure is not listed as a covered service. The Plan says 
bitewing x-rays are not listed as a covered service. The Plan says periapical x-rays are not listed as a covered 
service. The Plan also says you did not elect to purchase the optional supplemental dental 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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the unspecified 
preventive procedure (D1999), bitewing x-rays (D0274), the initial periapical x-ray (D0220), and the additional 
periapical x-ray (D0230) provided on May 13, 2020.
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 meet the criteria for an LTACH 
admission. You say that an LTACH is the most appropriate level of care at this time. You say that you are 
medically stable and require prolonged hospitalization and close physician/specialist monitoring. The Plan 
denied your request. The Plan says transfer to an LTACH is not medically necessary. The Plan says that 
continued management can be provided in the acute care hospital until the enrollee's course of care is complete. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found ongoing care needs include respiratory support with oxygen supplementation, 
ventilatory weaning, and tracheostomy care, surveillance laboratory studies, tube feedings, 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. 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that the records provided support the need for 
SNF care. The Plan denied your request. The Plan says the enrollee's current condition does not require daily 
skilled services. The Plan says that the enrollee does not meet the criteria for coverage of SNF care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral and 
inhaled medications. This included Coumadin which was dose adjusted based on the enrollee's PT/INR. The 
enrollee had stable vital signs and used oxygen via a nasal cannula. The enrollee received physical therapy in 
the acute hospital. The enrollee was at a minimal/contact guard assist to total assist level with transfers and he 
could ambulate 5 feet with contact guard to minimal assist. The enrollee required varying assist with activities 
of daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy 
service needs. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient 
basis in a skilled nursing facility setting. 
 
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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
January 1, 2020 to January 31, 2020. 
 
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says submitted HIPPS code 3CHK4 is not valid as 
of December 31, 2019 and also there is no RAP claim found. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the 
submitted claim includes an invalid HIPPS code. Per CMS, HIPPS code 3CHK4 was effective from January 1, 
2008 through December 31, 2019. Additionally, there is no evidence that a RAP was submitted.. Therefore, we 
decided that the Plan does not have to pay for the home health services provided to the enrollee from January 1, 
2020 to January 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process 
stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar; single level (CPT Code 22869). 
 
You asked the Plan to pre-approve the device. You say that the device is necessary. The Plan denied your 
request. The Plan says this device is considered investigative. 
 
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 device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the device is experimental. More research is needed to show safety and efficacy. It is not 
needed in this case. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without open 
decompression or fusion, including image guidance when performed, lumbar; single level (CPT Code 22869).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 
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 admission to a SNF. Our reviewer says 
that the enrollee does not meet criteria for SNF admission. Our physician reviewer found the enrollee is with 
hypertension and atrial fibrillation and was admitted to acute care on 10/10/20 with a cerebral vascular 
accident. From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. Her 
lungs were clear. Regarding rehabilitation services, the enrollee received physical therapy, speech therapy and 
occupational therapy in the acute hospital. The enrollee was at a stand by assist level with functional mobility 
including gait to 400 feet. The enrollee required varying assist with activities of daily living. She was treated 
for aphasia. 
 
There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The 
enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on February 4, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed with too many units. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 11102 is 1. You billed 2 units of this code, exceeding the MUE. 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 provided on February 4, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for Home Health Services (G0156, G0299) provided June 3, 
2019 to June 28, 2019. 
 
You asked the Plan to pay for the Home Health Services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says a RAP was not submitted for the services at issue. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Medicare rules state that HHA's should submit the RAP as soon as possible after care begins in order to assure 
being established as the primary HHA for the beneficiary. 
 
We find that CPT codes G0156 & G0299 are not supported in the medical record. Specifically, the record 
shows that the Home Health Agency did not submit a Request for Anticipated Payment (RAP) for these 
services. Based on this information, we decided that Medicare rules for coverage of the Home Health Services 
have not been met. Therefore, we decided that the Plan does not have to pay for Home Health Services (G0156, 
G0299) provided June 3, 2019 to June 28, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on March 24, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says too many units of this code were billed.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied.

In this case, the MUE for CPT code 37220 is 1. You billed 2 units of this code, exceeding the MUE. 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 provided on March 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for physician services provided by a 
participating provider on May 8, 2020. 
 
You asked the Plan to waive the coinsurance for physician services. You say that you were told that you would 
not owe anything. The Plan denied your request. The Plan says the correct coinsurance has been applied. 
 
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 20% 
coinsurance for physician/practitioner services/in-network/provider services.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for physician services. The total allowed 
amount is $162.16. The total amount you are being asked to pay is $32.43 ($162.16 x 20% = $32.43). 
Physician services fall within the physician/practitioner services/in-network/provider services 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 coinsurance for physician services provided by a participating provider on 
May 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided 
that the Plan does not have to pre-approve a pneumatic compression device (E0676).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMs system. 
 
You asked the Plan to pre-approve the CardioMEMs system. You say that the CardioMEMs system is indicated 
for wirelessly measuring and monitoring pulmonary artery pressure and heart rate in New York Heart 
Association Class III heart failure patients who have been hospitalized for heart failure in the previous year. 
You say that the hemodynamic data is used by physicians for heart failure management and with the goal of 
reducing heart failure hospitalizations. The Plan denied your request. The Plan says the studies done on the use 
of the requested device have not shown it to be as good as or better than the standard treatment for heart failure 
management. 
 
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 CardioMEMs system. Our reviewer 
says that the requested device is not considered medically reasonable and necessary in this case. Our physician 
reviewer found therapy change based on data obtained from a CardioMEMs device has been demonstrated in 
only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns 
have been raised about potential bias in this trial calling into question the results. Therefore, the efficacy of the 
CardioMEMS device is uncertain at this time according to leading authorities and is not recommended in 
current guidelines for the treatment of heart failure. Our physician reviewer found that the device should still be 
considered experimental or investigational. 
 
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 CardioMEMs system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a CardioMEMs system.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on March 29, 2020. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 the Guardant360 testing is not supported in the medical record. Specifically, this service should be 
billed with code 81479. In addition, the appropriate DEX Z code identifier should be entered adjacent to the 
code in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of 
the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 testing provided on March 29, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on February 16, 2020. 
 
You asked the Plan to pay for ambulance services. You say that the claim should be paid. The Plan denied your 
request. The Plan says your claims would be covered by original Medicare on the date of hospice election, until 
the first day of the following month in which Hospice was revoked which would be March 01, 2020. The Plan 
states the provider needs to submit their request for reimbursement to Original Medicare for services rendered 
on February 16, 2020. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on February 16, 2020. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for ambulance services 
provided on February 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Home infusion therapy (S9328) provided February 20, 2020 
to April 8, 2020. 
 
You asked the Plan to pay for the infusion therapy. You say that the Plan has denied the claim stating not a 
payable code. This enrollee also has other dates of services that was allowed and paid by the plan. Please 
reprocess this appeal for payment. The Plan denied your request. The Plan says the claim was billed with a 
code that is not 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, the CPT Code Manual definition of code S9328 is Home infusion therapy, implanted pump pain 
management infusion; administrative services, professional pharmacy services, care coordination, and all 
necessary supplies and equipment (drugs and nursing visits coded separately), per diem. 
 
We find that CPT code S9328 is not supported in the medical record. Specifically, 'S' codes (temporary codes) 
are used to report drugs, services and supplies for which there are no national codes. These codes are not 
payable by Original Medicare. For S9328, the guidelines are that the Plan does not recognize this code for non-
participating providers. Based on this information, we decided that Medicare rules for coverage of the infusion 
therapy have not been met. Therefore, we decided that the Plan does not have to pay for Home infusion therapy 
(S9328) provided February 20, 2020 to April 8, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the thoracic spine. 
 
You asked the Plan to pre-approve the MRI. You say that the records provided support the need for the 
requested MRI. The Plan denied your request. The Plan says that there is no evidence of any pertinent clinical 
findings suggestive of disease progression or recurrence of the enrollee's condition. The Plan says that the 
enrollee has renal cell carcinoma and a recent thoracic spine biopsy was negative. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the 
requested MRI is medically reasonable and necessary. Our physician reviewer found the enrollee has been 
diagnosed with renal cell cancer and there is a suspicion of progression. Our physician reviewer says that 
because the treating physician feels there may be progression, a follow-up MRI is medically reasonable and 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
magnetic resonance imaging (MRI) of the thoracic spine.  
 
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.