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 unable to care for yourself. The Plan denied 
your request. The Plan says that the coverage criteria has not been met. 
 
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 that you do not have complex nursing or rehabilitation needs. While the medical 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 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 IRF. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve the ventilator. You say that it is felt that the ventilator is necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the enrollee does not require the level of 
support of the requested ventilator. 
 
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 the ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable and necessary. Our physician reviewer found the provided 
medical records document chronic respiratory failure consequent to chronic obstructive pulmonary disease and 
heart failure. The records show that the ventilator is being requested for use in average volume-assured 
pressure support (AVAPS) mode with auto-titration. This functionality can be provided by a bilevel positive airway pressure (BiPAP) device with AVAPS and back-up rate. The rules do not allow coverage for a 
ventilator when used as a BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a portable ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept intraosseous basivertebral nerve ablation 
procedure. 
 
You asked the Plan to pre-approve the requested Intracept procedure. You say that there is sufficient literature 
to support that this procedure will be useful for the enrollee. The Plan denied your request. The Plan says the 
requested procedure remains experimental at this time. 
 
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 requested Intracept procedure. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the Intracept procedure is experimental. More research is needed to support this 
procedure. 
 
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 requested Intracept procedure have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the Intracept intraosseous basivertebral nerve ablation procedure.
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 enrollee is unable to care for herself. The Plan 
denied your request. The Plan says that the coverage criteria has not been met. 
 
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 that the enrollee does not have daily skilled nursing needs that require the 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 and/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 pre-approve a home ventilator (E0466) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a home ventilator. You say that you disagree with the denial. The Plan 
denied your request. The Plan says you must use network providers and suppliers to get your medical care and 
services. There are in network providers available. 
 
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 
a home ventilator (E0466) 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 February 6, 2022, 
through February 14, 2022. 
 
You asked the Plan to pay for the home health services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the provider did not bill as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the home health services have not been met. There is an NOA 
submitted with the "from" date as January 07, 2022, representing the continued care in 2022. However, the 
claim for the 30-day period of care, i.e., from February 06, 2022, to February 14, 2022, is submitted incorrectly 
with the admit date as December 08, 2021. Per Medicare guidelines, The HHA enters a date of admission 
matching the from date on the first date of care in an admission. On subsequent periods of care, the HHA 
continues to submit the admission date reported on the first period of care. Therefore, we find the Medicare 
rule for payment of this February 06, 2022, to February 14, 2022, claim has not been met and could not be 
processed for payment. Therefore, we decided that the Plan does not have to pay for the home health services 
provided from February 6, 2022, through February 14, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 93010 billed for date of service January 10, 2022. 
 
You asked the Plan to pay for code 93010. You say that the patient had multiple services on this date with 
different providers. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid 
claim and was correctly denied. The Plan states that it already paid for code 93010 provided by the provider 
listed on the claim in dispute. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on February 17, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date 
by the same provider. Based on this information, we decided that the Medicare rules for code 93010 have not 
been met. Therefore, we decided that the Plan does not have to pay for code 93010 billed for date of service 
January 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone graft at time of implant placement (D6104) for 
teeth numbers 7 and 10, gum surgery (D4266) for tooth number 10, implant placement (D6010) for teeth 
numbers 7 and 10, and a prefabricated abutment (D6056) for tooth number 10. 
 
You asked the Plan to pre-approve a bone graft at time of implant placement (D6104) for teeth numbers 7 and 
10, gum surgery (D4266) for tooth number 10, implant placement (D6010) for teeth numbers 7 and 10, and a 
prefabricated abutment (D6056) for tooth number 10. You say that that this is medically necessary. You also 
say your provider advised this is the only thing you can have done. The Plan denied your request. The Plan 
says the requested codes/services are not listed, and are therefore excluded from coverage. 
 
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 a 
bone graft at time of implant placement (D6104) for teeth numbers 7 and 10, gum surgery (D4266) for tooth 
number 10, implant placement (D6010) for teeth numbers 7 and 10, and a prefabricated abutment (D6056) for 
tooth number 10.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 93325 provided on August 31, 2021. 
 
You asked the Plan to pay for procedure code 93325. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that they were unable to make a determination 
within the allotted time frame. 
 
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. In this case, the Plan originally denied payment for services stating that the 
procedure exceeds the maximum number of services allowed for a single date of service. However, the Plan 
provided no evidence based on Medicare criteria that the services were not billed correctly. Therefore, we 
decided that the Plan has to pay for procedure code 93325 provided on August 31, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown - porcelain/ceramic tooth #'s 10 and 11 
(D2740), and prefabricated post and core in addition to crown tooth #'s 10 and 11 (D2954). 
 
You asked the Plan to pre-approve the dental services. 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 crown - porcelain/ceramic (D2740) one per 60 month(s), per patient, same tooth and 
prefabricated post and core in (D2954) was exhausted on date of service September 24, 2022. Therefore, we 
decided that the Plan does not have to pre-approve a crown - porcelain/ceramic tooth #'s 10 and 11 (D2740), 
and prefabricated post and core in addition to crown tooth #'s 10 and 11 (D2954).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on June 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says Based on a review of the information received, it was 
determined that the alternate benefit applied to cover the crown services rendered on June 14, 2022. Per your 
Evidence of Coverage, if the plan determines that a less expensive alternate procedure, service, or course of 
treatment can be performed in place of a proposed treatment to correct a dental condition and the alternate 
treatment will produce a professionally satisfactory result, then the maximum the Plan will allow will be the 
charge for the less expensive treatment. You will also be responsible for the difference between the allowed 
amounts and 50% coinsurance for Class 3 Major Services. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay the 
difference between the allowed amounts and a 50% coinsurance for Class 3 Major Services.  
 
You have been asked to pay $471.61 for dental services. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for dental services on June 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (procedure code 01844 and 99100) 
provided to the enrollee on June 14, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for, as the claim is coded correctly. 
The Plan denied your request. The Plan says this was not reported correctly. 
 
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 99100: 
 
Anesthesia for vascular shunt, or shunt revision, any type (eg, dialysis) 
 
CPT 01844: 
 
Anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to 
code for primary anesthesia procedure) 
 
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 CPT 99100 has a status indicator 
of B. This is a bundled code that should be reported separately. In terms of CPT 01844, this anesthesia service 
requires a modifier to identify if the service was personally performed, medically directed, or at the medically 
supervised rate. Therefore, the procedure cannot be verified. 
 
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 anesthesia services (procedure code 01844 and 99100) provided to the enrollee on June 14, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the E-Stim supplies provided on June 19, 2022. 
 
You asked the Plan to pay for the E-Stim supplies. You say that these items are covered. The Plan denied your 
request. The Plan says you did not satisfy documentation requirements for coverage. 
 
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 a valid physician order to support medical necessity for the supplies provided in 
this case. Specifically, the Plan contacted the provider who you contend ordered the supplies at issue.  The 
provider confirmed that they did not order the supplies and they do not know the patient to whom the supplies 
were sent. Therefore, we decided that the Plan does not have to pay for the E-Stim supplies provided on June 
19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve office visits. You say that the records provided support the services. The 
Plan denied your request. The Plan says services must be obtained from 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 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 
office visits to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual wellness visit provided on June 8, 2022. 
 
You asked the Plan to pay for the annual wellness visit. You say that you have never been responsible for these 
charges in the past. The Plan denied your request. The Plan says the service is a covered benefit, but the 
enrollee has exceeded the frequency limitation in the benefit plan. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
The file shows you received the AWV benefit on February 22, 2022. Therefore, we decided that the Plan does 
not have to pay for an annual wellness visit provided on June 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a negative pressure wound therapy vacuum to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve wound vacuum. You say that the enrollee's previous Plan always directed 
the enrollee to this provider for supplies. The Plan denied your request. The Plan says this provider is out-of-
network with the Plan and the needed supplies can be obtained within the Plan network. 
 
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 
a negative pressure wound therapy vacuum to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an office or other outpatient visit for the evaluation and management of 
a new patient, which requires a medically appropriate history and/or examination and low level of medical 
decision making (CPT 99203) provided on June 1, 2022. 
 
You asked the Plan to pay for the office or other outpatient visit. You say that the member was new to the 
orthopedic surgery clinic. The Plan denied your request. The Plan says that payment was already made for 
same/similar procedure within a set time frame 
 
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. Neither of the prior two visits are shown to have been done by a nurse 
practitioner working for an orthopedist. There is no evidence that the enrollee was seen in the past 3 years by 
a nurse practitioner working for orthopedics. The Plans denial for billing for a new patient exam is not 
supported. Therefore, we decided that the Plan has to pay for an office or other outpatient visit for the 
evaluation and management of a new patient, which requires a medically appropriate history and/or 
examination and low level of medical decision making (CPT 99203) provided on June 1, 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.