Persius/hicric huggingface dataset:
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 you are appealing the denial of acute inpatient 
rehabilitation admission. The Plan denied your request. The Plan says based on Medicare guidelines and the 
information we have about your condition you do not meet the requirements for approval. 
 
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 there are no complex nursing or rehabilitation needs. While you have a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that continued therapy is needed to improve mobility 
and decrease pain. The Plan denied your request. The Plan says that additional physical therapy is not 
medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the provided records do not document any acute or unstable 
medical conditions or injuries which would necessitate any further skilled therapy visits beyond what have 
already been approved. Records document you have been educated on your disease process and the use of your 
knee brace. No medical notes from your treating physician are provided documenting an order or need for 
additional skilled therapy services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapy visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 10 physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom abutments on tooth #28 and 29 (D6057) and 
abutment supported crowns on tooth #28 and 29 (D6059). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says custom abutments (D6057) and abutment supported 
crowns (D6059) are not covered by your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
custom abutments on tooth #28 and 29 (D6057) and abutment supported crowns on tooth #28 and 29 (D6059).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the breathing machine supplies to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the breathing machine supplies. You say that this equipment is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says there are in-network 
providers available to provide the equipment in question. 
 
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 
the breathing machine supplies to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you have dialysis 
treatments and have no other way of getting to them. You say that if you do not get this necessary treatment, 
you could get really sick and possibly die. The Plan denied your request. The Plan says you have exhausted all 
one-way routine transportation trips for the benefit year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 20 one-way routine transportation trips per year.  
 We looked at your request, the records in the case file, and the rules. The records shows that the Plan has 
provided coverage for 20 one-way routine transportation trips in the 2022 calendar year. Based on this 
information, we decided that you have exhausted the Plan maximum benefit for coverage of routine 
transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine 
transportation trips.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that SNF services are medically necessary. The Plan 
denied your request. The Plan says the patient does not meet SNF criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not qualify for SNF coverage. The enrollee does not have 
documented skilled nursing needs. The enrollee does not have documented skilled therapy needs.  Daily skilled 
services are not shown to be required to establish a maintenance program or to prevent deterioration of the 
enrollees condition.  The enrollees care needs can, as a practical matter, be provided at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for an injection procedure (procedure code 38792) provided to the enrollee 
on March 10, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that Current Procedural Terminology (CPT) code 38792-XU-RT-GC remains not supported, as 
the records do not support that this procedure or service was distinct or independent from other services 
performed. 
 
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 38792 is "Injection procedure; radioactive tracer for identification of sentinel node." 
 
We asked our coder 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 services at issue in 
this case were supported by the medical records. Our reviewer found CPT 38792 was an injection of 
Technetium isotope for lymphatic mapping on 3/10/22 and was separate and distinct from the surgical 
procedure. The injection was thoroughly documented in the operative report and should be paid. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
an injection procedure (procedure code 38792) provided to the enrollee on March 10, 2022.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry (83789) 
billed for date of service April 5, 2022. 
 
You asked the Plan to pay for mass spectrometry services. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says they have agreed to pay for the 
drug testing services (G0481); however, the payment for this service is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of mass spectrometry services have not been met. Specifically, we find that the testing described by 
the billed code is considered specimen validity testing which is not separately payable. Therefore, we decided 
that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry (83789) billed for date 
of service April 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the open treatment of metatarsophalangeal joint dislocation 
services coded 28645 provided on November 2, 2021. 
 
You asked the Plan to pay for the open treatment of metatarsophalangeal joint dislocation services. You say 
that you disagree with the Plan's denial. The Plan denied your request. The Plan says the services billed are not 
supported by the documentation. 
 
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 28645 is open treatment of metatarsophalangeal joint 
dislocation, includes internal fixation, when performed. 
 
We find that CPT code 28645 is not supported in the medical record. Specifically, the operative report did not 
include documentation of an open treatment of metatarsophalangeal joint dislocation, includes internal fixation, 
when performed. Based on this information, we decided that Medicare rules for coverage of the open treatment 
of metatarsophalangeal joint dislocation services have not been met. Therefore, we decided that the Plan does 
not have to pay for the open treatment of metatarsophalangeal joint dislocation services coded 28645 provided 
on November 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a core buildup (D2950) provided on May 10, 2022. 
 
You asked the Plan to pay for a core buildup. You say that you do not understand why this service is not 
covered. The Plan denied your request. The Plan says the service at issue 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 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 core 
buildup (D2950) provided on May 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary and mandibular denture (D5110 
and D5120) and panoramic radiographic imaging (D0330) provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the dental services. You say that you are having a lot of pain. You say that 
your old dentures are in a bad condition. 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 D5110 and D5120 was exhausted on date of service May 8, 2019, and your benefit for 
D0330 was exhausted on date of service February 9, 2022. Therefore, we decided that the Plan does not have to 
pre-approve a complete maxillary and mandibular denture (D5110 and D5120) and panoramic radiographic 
imaging (D0330) provided by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on May 10, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the corrected claims have not been received. 
 
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 the denied codes is: 
 
CPT 80307: 
 
Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument 
chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), 
chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, 
DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when 
performed, per date of service 
 
 
 CPT 99213: 
 
Office or other outpatient visit for the evaluation and management of an established patient, which requires a 
medically appropriate history and/or examination and low level of medical decision making. When using time 
for code selection, 20-29 minutes of total time is spent on the date of the encounter. 
 
We asked our coder 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 services at issue in 
this case were not supported by the medical records. Our reviewer found that the enrollee was seen in the office 
on 2/10/22 for neck pain and bilateral shoulder pain. The case file does not contain documentation of drug 
testing services for this date of service. 
 
We looked at this coder'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 drug testing services provided to the enrollee on May 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scaling and root planing (D4341) provided on 
June 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that without this service the tooth roots will 
deteriorate, and teeth will fall out. The Plan denied your request. The Plan says periodontal scaling and root 
planing (D4341) is not covered under your supplemental benefit. 
 
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 the 
periodontal scaling and root planing (D4341) provided on June 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 85027 and 80050 billed for date of service 
July 9, 2020. 
 
You asked the Plan to pay for procedure codes 85027 and 80050. You say that this claim should be reprocessed 
and the lines which were denied should be paid. The Plan denied your request. The Plan says payment for code 
85027 is bundled into payment for code 85025. 
 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 85027 
is a column II code to column I code 85025. This claim has not been billed with an appropriate modifier to 
bypass the edit. In addition, the rules say that code 80050 (general health panel) is considered a non-covered 
code. Medicare does not cover or pay for services billed under this code. Based on the claim submitted, 
Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 85027 and 80050 billed for date of service July 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete denture - maxillary (D5110) provided March 
31, 2022. 
 
You asked the Plan to pay for the dental services. You say that you had issues with your previous dentures. 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 October 7, 2021. 
Therefore, we decided that the Plan does not have to pay for the complete denture - maxillary (D5110) 
provided March 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 you need rehab to build your function.  You said that 
you have been in the hospital since July and cannot go home or you will be a danger to yourself. The Plan 
denied your request. The Plan says 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 the complexity of your nursing, medical and rehabilitation needs do not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive 
rehabilitation therapy 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 inpatient rehabilitation facility. 
You continue to have a need for skilled therapy with ongoing safety concerns and a potential for functional 
improvement however, the documentation doesnt support that you would meet criteria for admission to an 
acute inpatient rehabilitation facility.  There is no indication that you would require skilled rehabilitation in an 
IRF, participating in rehab services 15 hours a week, under the supervision of a physician with at least 3 visits 
weekly to regain or maintain her functional status.  You can receive further services at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.