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

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that you would like to stay with this provider, and 
you did not know they were out-of-network. The Plan denied your request. The Plan says network providers 
must be used when choosing your PCP. 
 
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 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 2, 2022, to June 
28, 2022. 
 You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says a required NOA was not submitted. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, an NOA was not submitted. As more than 30 days passed between the timely filing date and the 
NOA receipt, no payment can be made on this claim. Therefore, we decided that the Plan does not have to pay 
for the home health services provided from June 2, 2022, to June 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (88341, 88342, 88360, and 88381) 
provided on February 16, 2022. 
 
You asked the Plan to pay for procedure codes 88341, 88342, 88360, and 88381. You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not 
covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that modifier -26 is required for separate payment of 
the PC services when furnished in a different payment locality than the TC. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with the required -26 
modifier to allow for separate PC payment. Therefore, we decided that the Plan does not have to pay for the 
laboratory services (88341, 88342, 88360, and 88381) provided on February 16, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic procedure provided on July 15, 2022. 
 
You asked the Plan to pay for the therapeutic procedure. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as 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 97110 is therapeutic procedure, 1 or more areas, each 15 
minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. 
 
We find that CPT code 97110 is not supported in the medical record. Specifically, this code was submitted with 
modifier GP/CQ. The therapy service modifier (GP) requires a therapy service revenue code. The claim is not 
payable as billed. Based on this information, we decided that Medicare rules for coverage of the therapeutic 
procedure have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic 
procedure provided on July 15, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve occupational therapy to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve occupational therapy. You say that you have tried to find good occupational 
therapy in-network but have not gotten any. The Plan denied your request. The Plan says the enrollee must 
receive care from 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. 
 
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 
occupational therapy to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve these 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. Medicare rules say that Prolia is covered when specific criteria are met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the submitted records do not document 
that you have a history of treatment related to progression of disease and ongoing risk factors. You have not 
tried and failed other available treatments for osteoporosis. The criteria for coverage are not met and the Prolia is not reasonable or 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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the amount applied towards the deductible for the ophthalmological 
exam (92014) provided on June 21, 2022. 
 
You asked the Plan to waive the amount applied towards the deductible for procedure code 92014. You say that 
you feel you should not be responsible for this cost share amount, and you would like the Plan to reconsider 
your request. The Plan denied your request. The Plan says that this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $40 copayment for Vision Services.  
 
The Plan says you must pay $112 of your remaining deductible for procedure code 92014. Based on the Plan 
contract, however, you cannot be asked to pay more than a $40 copayment for procedure code 92014. The file 
clearly shows that you had already met your $325 deductible before this exam took place. Therefore, we 
decided that the Plan has to waive the amount applied towards the deductible for the ophthalmological exam 
(92014) provided on June 21, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 24-trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need additional 
transportation to get to your medical appointments. The Plan denied your request. The Plan says the requested 
trips exceed your trip limit. 
 
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 24 trips per year.  
 We looked at your request, the records in the case file, and the rules. The Plan provided documentation 
showing that 24 routine transports have already been covered. 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 trips for routine transportation beyond the Plan's 24-trip limit.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hydration intravenous infusion services coded 96361 
provided on June 3, 2022. 
 
You asked the Plan to pay for the hydration intravenous infusion services. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that specific ICD-10-CM codes support medical 
necessity and provide coverage for CPT code 96361. Any code not listed is not covered. 
 
We looked at the file and Medicare rules. This service was billed with diagnosis code R51.9 (headache, 
unspecified). Diagnosis R51.9 is not listed as a covered diagnosis code that allows payment for code 96361. 
Based on this information, we decided that Medicare rules for coverage of the hydration intravenous infusion 
services have not been met. Therefore, we decided that the Plan does not have to pay for the hydration 
intravenous infusion services coded 96361 provided on June 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested item is a medical necessity for 
you. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the requested item is not medically reasonable and necessary in this case. Our physician reviewer found 
that the provided records document that the home ventilator is being requested for use in average volume 
assured pressure support (AVAPS) mode with auto-titration (AE) which could be provided by a BiPAP device 
with AVAPS and a back-up rate. 
 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (ESI) for the lower 
back (64483). 
 
You asked the Plan to pre-approve a repeat ESI for the lower back. You say that the last injection was on 
August 24, 2022, and it provided the enrollee with pain relief of 60% for 6 hours. The Plan denied your 
request. The Plan says the enrollee's prior injection on August 24, 2022, provided some relief for only 6 hours, 
which would not meet guidelines for medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat ESI when the first injection directly and 
significantly provided improvement of the condition being treated may be considered medically reasonable and 
necessary when the medical record documents at least 50% of sustained improvement in pain relief and/or 
improvement in function measured from baseline using same scale for at least three months. 
 
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 repeat ESI for the lower back. Our 
reviewer says that the request to repeat the injection is deemed not medically reasonable or necessary. Our 
physician reviewer found the medical record does not document at least 50% of sustained improvement in pain 
relief and/or improvement in function measured from baseline using the same scale for at least three months 
from the last ESI. 
 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 repeat ESI for the lower back have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a repeat epidural steroid injection (ESI) for the lower back (64483).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an echocardiogram to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an echocardiogram. You say that you were recently diagnosed with heart 
failure and are in a very delicate condition. The Plan denied your request. The Plan says you must receive your 
care from 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. 
 
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 
an echocardiogram to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent detection billed for date of service July 19, 
2022, indicated by procedure code 87801. 
 
You asked the Plan to pay for procedure code 87801. You say that the service at issue was a medical necessity 
for the enrollee. The Plan denied your request. The Plan says the available records do not support the service 
indicated by code 87801. 
 
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 87801 is: Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; amplified probe(s) technique. 
 
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 procedure code 87801. Our reviewer says that procedure 
code 87801 does not meet criteria for payment. Our reviewer found that procedure code 87801 is the lab 
process of the specimen from a direct source suchs as sputum, pleural fluid from chest, throat swab or 
nasopharyngeal washings. The medical documentation shows a UTI/STD was performed; there is a more 
appropriate code for this procedure and it has already been billed. Medical documentation does not support the 
use of code 87801. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 87801 have not been met. Therefore, we decided that the Plan 
does not have to pay for infectious agent detection billed for date of service July 19, 2022, indicated by 
procedure code 87801.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two removals of torus mandibularis (D7473 x2). 
 
You asked the Plan to pre-approve a removals of torus mandibularis. You say that you need a bone graft before 
you get dentures. The Plan denied your request. The Plan says this service is not covered under your benefit 
package. 
 
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 two 
removals of torus mandibularis (D7473 x2).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the requested acute inpatient 
hospital care is a medical necessity for you. The Plan denied your request. The Plan says the request is 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 pre-approve acute inpatient hospital care. Our 
reviewer says that inpatient admission is not reasonable and necessary in this case. Our physician reviewer 
found that detailed documentation is not evident in the case record regarding a significant past and/or current 
medical history that would place you at increased risk for peri-surgical complications requiring an inpatient 
stay. There is no compelling rationale presented or extenuating circumstances noted to support the medical 
necessity of this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on June 26, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for physical therapy. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says under certain circumstances, members may obtain services from out-of-
network providers. Newly eligible members who are undergoing an existing course of treatment under the care 
of an out-of-network provider at the time of eligibility may continue to obtain services from that provider for 
up to forty-five (45) days or until treatment can be transitioned to an in-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 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 physical therapy provided on June 26, 2021, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment of root canal obstruction; non-surgical access 
(D3331), Tooth 4. 
 
You asked the Plan to pre-approve dental services. You say that that you need the requested services because 
you are in pain. Also, you say that you would like this completed before you go out of the country. The Plan 
denied your request. The Plan says this service is not covered under your Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Treatment of root canal 
obstruction; non-surgical access (D3331) is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested treatment of root canal 
obstruction; non-surgical access (D3331) is not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to pre-approve treatment of root canal obstruction; non-surgical access (D3331), 
Tooth 4.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging (MPI). 
 
You asked the Plan to pre-approve MPI. You say that the services are necessary. The Plan denied your request. 
The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that MPI is covered under certain circumstances. 
 
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 MPI. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee's pre-test probability for an 
abnormal test is low and there is no documentation that the electrocardiogram (ECG) shows an uninterpretable 
pattern. There is no evidence provided that would support the need for radionuclide stress testing. In summary, 
there is insufficient documentation to support the medical necessity for the requested radionuclide stress testing 
in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MPI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve myocardial perfusion imaging (MPI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intravenous sedation (D9243) provided by a participating 
provider on June 30, 2022. 
 
You asked the Plan to pay for intravenous sedation. You say that you believe you are being overcharged. The 
Plan denied your request. The Plan says these services have been correctly denied. 
 
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 
intravenous sedation (D9243) provided by a participating provider on June 30, 2022.