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

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) 
provided on December 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that this was for an emergency treatment of a broken 
tooth. You also say you are requesting the claim to be paid. The Plan denied your request. The Plan says you 
were enrolled in the optional supplemental dental benefits in 2022 which allowed for an additional exam for the 
year. Your benefit for limited oral evaluation - problem focused 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 limited oral evaluation - problem focused was exhausted on date of service January 
19, 2022, and July 26, 2022. Therefore, we decided that the Plan does not have to pay for a limited oral 
evaluation - problem focused (D0140) provided on December 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) and bilateral duplex scan (93970) 
provided on October 04, 2022. 
 
You asked the Plan to pay for the office visit (99213) and bilateral duplex scan (93970). You say that the 
services should be covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care 
is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit (99213) 
and bilateral duplex scan (93970) provided on October 04, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox injection. 
 
You asked the Plan to pre-approve the services. You say that the enrollee has had slow transit constipation for a 
few years. The Plan denied your request. The Plan says treatment of slow transit constipation is not listed as an 
indicated use. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
Slow transit constipation is not a Food and Drug Administration (FDA) approved indication for Botox. 
Additionally, it is not a covered off-label indication. 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 pre-
approve Botox injection.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cardiac catheterization (93458). 
 
You asked the Plan to pre-approve a cardiac catheterization. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a cardiac catheterization. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee has not had a non-invasive work-up such as a stress test. Guidelines 
do not support a need for cardiac catheterization in this 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 a cardiac catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a cardiac catheterization (93458).
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 a skilled nursing facility will not give the enrollee 
the opportunity to return to prior level of function. The Plan denied your request. The Plan says the enrollee can 
safely receive the services needed in another setting such as a skilled nursing facility. 
 
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 enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a nasal endoscopy provided on August 22, 2022. 
 
You asked the Plan to pay for the nasal endoscopy. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not forwarded the medical records related to this 
request. Without this information, we are unable to determine if the services were urgent or emergent in nature. 
It is the burden of the Plan to substantiate their denial with evidence. In this case, the Plan's denial is not 
substantiated, so we must find in your favor. Therefore, we decided that the Plan has to pay for a nasal 
endoscopy provided on August 22, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided on August 19, 2022. 
 
You asked the Plan to pay for the outpatient hospital services. You say that this service needs to be authorized. 
The Plan denied your request. The Plan says you billed a code that is not allowed under OPPS. 
 
The Plan must follow Medicare rules. Medicare rules say that on Outpatient Prospective Payment System 
(OPPS) claims, codes with a status indicator of B are not recognized by OPPS when submitted on an outpatient 
hospital Part B bill type (12x and 13x). These codes are not paid under OPPS . 
 
The Outpatient Prospective Payment System (OPPS) Addendum B shows that one of the billed codes on this 
claim (99211) has a status indicator of 'B'. The records also show that you billed with a Type of Bill 137.  The 
rules are clear that if you bill on a claim with a Type of Bill of 137 and you bill a code that has a status 
indicator of B, that claim is not payable.  OPPS claims cannot be paid if individual line items are incorrect. 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient hospital services have not been met. Therefore, we decided that the Plan does not 
have to pay for outpatient hospital services provided on August 19, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan. 
 
You asked the Plan to pre-approve the PET scan. You say that the requested PET scan is necessary to rule out 
Alzheimer's Disease versus dementia. The Plan denied your request. The Plan says the criteria for coverage 
have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found that per the National Coverage 
Determination (NCD), this service is only covered to differentiate between Alzheimer's Disease (AD) and 
frontotemporal dementia (FTD) in individuals who meet diagnostic criteria for both conditions. The records 
provided for review did not show that this requirement for coverage had been met. The enrollee was not noted 
to meet diagnostic criteria for either AD or FTD. Therefore, the request would not meet the NCD requirements for coverage. 
 
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET scan.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulation supplies provided on November 3, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the billed code is an accepted procedure code. 
The Plan denied your request. The Plan says documentation supporting the enrollee-provider relationship is 
needed. 
 
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 current relevant medical records which support medical necessity for the supplies 
provided in this case. Based on this information, we decided that the Medicare rules for coverage have not been 
met. Therefore, we decided that the Plan does not have to pay for the electrical stimulation supplies provided 
on November 3, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the behavioral health services provided on November 23, 
2022. 
 
You asked the Plan to pay for the behavioral health services. You say that the service should be covered. The 
Plan denied your request. The Plan says Licensed Mental Health Counselors are not eligible to participate in 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the behavioral health services provided 
on November 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies billed for date of service 
December 3, 2022. 
 
You asked the Plan to pay for the billed services. You say that the billed code is an accepted procedure code. 
The Plan denied your request. The Plan says medical records are needed to support the enrollee-provider 
relationship. 
 
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 current and relevant medical records which support medical necessity for the 
supplies provided in this case. Based on this information, we decided that the Medicare rules for coverage have 
not been met. Therefore, we decided that the Plan does not have to pay for the electrical stimulator supplies 
billed for date of service December 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a functional electrical stimulation (FES) device 
(E0770). 
 
You asked the Plan to pre-approve a FES device. You say that this device would help you to walk correctly and 
stop further damage to your hip. The Plan denied your request. The Plan says the requested FES is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage for the use of NMES/FES is limited to 
SCI patients for walking, who have completed a training program which consists of at least 32 physical therapy 
sessions with the device over a period of three months. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a FES device have not been met. Specifically, the file does not support that you have a spinal cord 
injury. Therefore, we decided that the Plan does not have to pre-approve a functional electrical stimulation 
(FES) device (E0770).
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 the services are medically necessary for the 
enrollee's medical needs. The Plan denied your request. The Plan says the services the enrollee needs can be 
provided safely in another setting such as a skilled nursing facility. 
 
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 enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep sedation (D9222 and D9223) and therapeutic 
parenteral drug (D9610). 
 
You asked the Plan to pre-approve the dental services. You say that it is medically necessary for you to get 
your tooth extracted. You say the out of pocket expense is not affordable to you. The Plan denied your request. 
The Plan says the services requested are non-covered codes under the dental benefit and not eligible for 
coverage under the medical benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve deep 
sedation (D9222 and D9223) and therapeutic parenteral drug (D9610).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on December 7, 
2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that you provided this item for use 
during the patient's surgical procedure to prevent blood clots. The Plan denied your request. The Plan says this 
item is not covered because it was not used in the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Medicare does not make separate payment for durable medical equipment used solely in a facility during a procedure. Therefore, we decided that the Plan 
does not have to pay for the pneumatic compression device provided on December 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 43281 billed for date of service April 11, 
2022. 
 You asked the Plan to pay for procedure code 43281. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 43281 is bundled into payment for code 43774. 
 
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 43281 
is a column II code to column I code 43774. 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 43281 billed for date of service April 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on September 19, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the codes are payable and not included in 
the dialysis rate. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-
related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable.  
 
 Laboratories should bill the facility directly for laboratory services as they are considered part of the composite 
rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay 
for the laboratory services related to end-stage renal disease (ESRD) provided on September 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99223 billed for date of service December 18, 2022. 
 
You asked the Plan to pay for code 99223. You say that this service should be paid separately because the 
physician went over labs, x-rays, and the patient's condition was discussed prior to the procedure being 
performed. The Plan denied your request. The Plan says this code is not separately payable because you did not 
bill it with an appropriate modifier.  Without a modifier, it is considered part of the global surgical package. 
 
The Plan must follow Medicare rules. Medicare rules say that visits by the same physician on the same day as a 
minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately 
identifiable service is also performed. This would be indicated by appending a modifier to the claim to indicate 
that it was a separately identifiable service.  
 
In this case, the visit in dispute (code 99223) was billed on the same date as a minor surgery (code 28002).  
You did not append a modifier to code 99223 to indicate that it was a separately identifiable service, so no separate payment can be made for this code. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 99223 have not been met. Therefore, we decided that the Plan does not have to pay for code 
99223 billed for date of service December 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with multiple 
power options and accessories. 
 
You asked the Plan to pre-approve a Group 3 PWC with multiple power options and accessories. You say that 
the enrollee requires both power tilt and power recline to manage the skin protection needs. You say that the 
enrollee has developed pressure ulcers to the area in contact with the seating surface. You also say that the 
suspension offered in a Group 3 PWC is necessary for the enrollee due to the knee amputations and impaired 
trunk stability. The Plan denied your request. The Plan says the enrollee does not meet the coverage criteria for 
the requested Group 3 power wheelchair. 
 
 
 The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, 
myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a 
Group 3 power wheelchair (PWC) with multiple power options and accessories.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 8, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on June 8, 2022.