Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on September 16, 2021. 
 
You asked the Plan to pay for the lab services. You say that medical records were submitted. The Plan denied 
your request. The Plan says an incorrect place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on September 16, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service September 
10, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service September 10, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a crown - porcelain/ceramic tooth #2 (D2740) provided on December 
20, 2021. 
 
You asked the Plan to pay for the crown - porcelain/ceramic tooth #2. You say that a prior claim for this tooth 
was never submitted to the Plan. You also say that you are concerned that your insurance is not covering a 
portion of the claims where you have coverage as stated in your dental policy. The Plan denied your request. 
The Plan says your benefit for coverage of crowns is exhausted because you previously received a crown for 
tooth #2 on March 23, 2017. 
 
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 rules also say that Medicare health plans must disclose benefit limitations in clear accurate terms. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not substantiated their denial reason by providing 
evidence of having provided coverage for a crown on the same tooth within the last 5 years. The Plan contract 
does not clearly disclose that there is a limitation to the benefit for crowns when a crown was provided for the 
same tooth within the last 5 years. The Plan contract language is limiting coverage to once every 5 years. Since 
there is no evidence of coverage for a crown on tooth #2 within the past 5 years, the benefit has not been 
exhausted. Therefore, we decided that the Plan has to pay for the crown  porcelain/ceramic tooth #2 (D2740) 
provided on December 20, 2021. 
 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit provided on July 2, 2022. 
 
You asked the Plan to pay for the emergency department visit. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the enrollee was enrolled in hospice for this date of service. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the emergency department visit provided on July 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit coded 99214 provided on July 29, 2022. 
 
You asked the Plan to pay for the office visit. 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 99214 is office or other outpatient visit for the evaluation 
and management of an established patient, which requires a medically appropriate history and/or examination 
and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total 
time is spent on the date of the encounter. 
 
 We find that CPT code 99214 is not supported in the medical record. Specifically, this service was billed with a 
place of service 22 (on campus-outpatient hospital). This code excludes services provided in emergency 
department, hospital observation, or hospital inpatient. This procedure code billed does not meet the associated 
place of service billed. This code is not payable as billed. Based on this information, we decided that Medicare 
rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to 
pay for the office visit coded 99214 provided on July 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and suspension 
sleeve (E0673), provided on July 8, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the items were medically 
necessary. The Plan denied your request. The Plan says these items are not covered for preventions of venous 
thromboembolism nor for treatment of peripheral artery disease during or after surgery.  
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. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
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. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) and suspension sleeve (E0673), provided on July 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea. 
 
You asked the Plan to pre-approve Eylea. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Eylea. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has diabetic macular edema.While the documenation supports that the enrollee is receiving 
Avastin, the documentation does not support that Avastin is less effective and/or likely have adverse effects for 
the enrollee. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an all-lower extremity prostheses, flex-walk system or equal 
(L5981) and lower extremity prosthesis, not otherwise specified, volume management system (L5999). 
 
You asked the Plan to pre-approve the prosthesis. You say that the denied codes represent a foot (L5981) and 
an adjustable socket (L5999). Both of these codes are essential in moving forward with the new prosthesis. The 
Plan denied your request. The Plan says that the requested socket does not have FDA approval and does not 
meet Medicare criteria as safe and effective. 
 
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 prosthesis. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee requires a prosthesis for mobility and accomplishing daily activities. The current 
prosthesis is no longer fitting due to volume change of the enrollee's residual limb and the foot/ankle is not 
functioning properly. The enrollee is noted to be a K3 level ambulator and is currently using a similar 
foot/ankle component. The enrollee's motor strength and range of motion are noted to be within normal limits 
in their lower extremities except for below the amputation. The enrollee is also noted to be on dialysis and 
experiences frequent changes in volume of their residual limb and therefore would require a volume 
management system for the appropriate fitting of the prosthesis. Therefore, the requested the requested flex 
walk system and volume management system are medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the prosthesis have not been met. Therefore, we decided that the Plan has to 
pre-approve an all-lower extremity prostheses, flex-walk system or equal (L5981) and lower extremity 
prosthesis, not otherwise specified, volume management system (L5999).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you would like to request reconsideration of 
the denied authorization. The Plan denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the SNF admission is medically necessary. The Plan 
denied your request. The Plan says the SNF admission is not medically necessary, reasonable, and appropriate 
for the enrollee's condition. 
 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 have identifiable skilled nursing needs but does not require the 
daily specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have 
daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional 
therapist. The enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a skilled 
nursing facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the semi-electric hospital bed billed with code E0260 for 
date of service March 15, 2022. 
 
You asked the Plan to pay for the hospital bed. You say that the billed code is a Medicare-covered code. The 
Plan denied your request. The Plan says you have provided no medical records to determine if the patient meets 
coverage criteria. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
 The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The only records provided are from more than six months prior to the date of service. The record 
shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, 
we decided that the Plan does not have to pay for the semi-electric hospital bed billed with code E0260 for date 
of service March 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontics (D6751) and crowns (D6751) for tooth #22, 
#23, #24, #25, #26, and #27. 
 
You asked the Plan to pre-approve the dental services. You say that the services were denied as not medically 
necessary. The Plan denied your request. The Plan says the x-rays show the enrollee is missing more than 1 
upper front tooth or only 2 lower front teeth. 
 
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. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
  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 dental services. Our reviewer says 
that the requested procedures are not medically necessary. Our physician reviewer found that the requested 
bridge from teeth #22 to #27 replacing #24 and #25 would not be medically necessary as the periodontal 
condition of the abutments is fair to poor, with about 50% bone remaining on tooth #22 and #23 and less than 
50% on tooth #26. Tooth #27 cannot be clearly seen on the supplied x-rays and a determination cannot be made 
as to the status of this tooth. There are other missing teeth in the arch and there appears to be substantial decay 
present on some of the remaining teeth. The long-term stability of the remaining abutment teeth cannot be fully 
established for the requested bridge, particularly with the severely compromised tooth #26 which is not a 
suitable abutment, and lack of information regarding tooth #27. 
 
The allowance requires that there are no other missing teeth in the same arch aside from third molars. In this 
instance missing teeth include #17, #18, #30 and #32. As there are other missing teeth aside from the 
anticipated two anterior teeth in the same arch, the Plan criteria would not be met. The periodontal condition of 
the teeth would also have to be adequate to support the bridge as well, and it is noted that there is moderate to 
severe compromise of the supporting teeth anticipated to be included in the bridge which would disqualify the 
requested service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve pontics (D6751) and crowns (D6751) for tooth #22, #23, #24, #25, #26, and #27.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup including any pins, when required (D2950) 
Tooth #12 and endodontic therapy, premolar tooth (excluding final restoration) (D3320) Tooth #12 provided on 
September 19, 2022. 
 
You asked the Plan to pay for dental services. You say that you went to a specialist who said you need these 
procedures. Therefore, you think they should be covered by insurance. The Plan denied your request. The Plan 
says these services are 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. Core buildup including any 
pins, when required (D2950) and endodontic therapy, premolar tooth (excluding final restoration) (D3320) are 
not covered under the Plans dental benefits. 
 
  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 core 
buildup including any pins, when required (D2950) Tooth #12 and endodontic therapy, premolar tooth 
(excluding final restoration) (D3320) Tooth #12 provided on September 19, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 13, 2022, to 
April 11, 2022. 
 You asked the Plan to pay for the home health services. The Plan denied your request. The Plan says the claim 
has not been billed correctly. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date and from date on the NOA do not 
match. The subsequent claim is unable to be paid due to an invalid NOA. Based on this information, we find 
that the Medicare rules for payment of the claim at issue have not been met. Therefore, we decided that the 
Plan does not have to pay for the home health services provided from March 13, 2022, to April 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total hip arthroplasty (27130) to be provided by a 
provider who has opted out of Medicare. 
 
You asked the Plan to pre-approve a total hip arthroplasty. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested provider has opted out of 
Medicare. 
 
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 are to be 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 pre-approve 
a total hip arthroplasty (27130) to be provided by a provider who has opted out of Medicare.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 28, 
2022. 
  You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on this date 
of service and the attached reports support the level of service. You say that the claim should be reconsidered 
for processing. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment 
for code 70496. 
 
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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 code 70450 billed for date of service August 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on July 26, 2022. 
 
You asked the Plan to pay for the billed services. You say that the equipment was issued for use during 
surgery. The Plan denied your request. The Plan says an ambulatory surgical center is not a home. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. We looked at the file and the rules. The claim information shows that the pneumatic compression device was 
provided in an ambulatory surgical center. The facility must furnish all necessary covered services to the 
beneficiary either directly or under arrangements made with outside providers. Based on this information, we 
decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that 
the Plan does not have to pay for the durable medical equipment provided on July 26, 2022.