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

 
We decided that the Plan does not have to pay for procedure codes 93010 and 99053 billed for date of service 
May 23, 2022. 
 
You asked the Plan to pay for procedure codes 93010 and 99053. You say that these services were reported 
correctly and are supported as billed. The Plan denied your request. The Plan says payment for code 93010 is 
bundled into payment for code 92950. In addition, procedure code 99053 is considered bundled and not 
separately payable. 
 
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 93010 
is a column II code to column I code 92950. This claim has not been billed with an appropriate modifier to 
bypass the edit. We also find that procedure code 99053 has a status indicator of B on the Physician Fee 
Schedule. This means that procedure code 99053 is not separately payable. Based on the claim submitted, 
Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 93010 and 99053 billed for date of service May 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve porcelain and high noble metal crowns (D2750) for 
teeth #4, #5, #6, #20, #21, #23, #24, #25, #26, #30 and #31. 
 
You asked the Plan to pre-approve dental crowns. You say that these crowns are medically necessary. The Plan 
denied your request. The Plan says crowns are not necessary to fix these 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 dental crowns 
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 dental crowns. Our reviewer says that 
the documentation provided does not meet the criteria for coverage of crown restorations for any of the 
indicated teeth being appealed. Our physician reviewer found the documentation provided does not show or 
indicate significant coronal breakdown due to caries or fracture of any of the teeth indicated to warrant crown 
restorations. 
 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 dental crowns have not been met. Therefore, we decided that the Plan does not 
have to pre-approve porcelain and high noble metal crowns (D2750) for teeth #4, #5, #6, #20, #21, #23, #24, 
#25, #26, #30 and #31.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an increase in home health aide services. 
 
You asked the Plan to pre-approve an increase in home health aide services. You say that an increase in home 
health aide services is medically necessary. The Plan denied your request. The Plan says this member is 
pending approval for Personal Care Attendant (PCA) services and was assessed August 15, 2022 by the PCA 
team to only meet criteria for 33.25-day hours/week. The member is not currently receiving PCA hours and 
lives alone. This member has not had any reported falls, emergency room visits, or inpatient admissions in the 
last 90-days to support increasing HHA hours. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an increase in home health aide 
services. Our reviewer says that an increase in home health aide services is not medically necessary. Our physician reviewer found that the clinical documentation does not show any clinical or functional status 
change. A letter by your family states that you have blindness, difficulty ambulating and breast cancer but none 
of these factors have been documented to change in status in the last evaluation, thus increased home health 
aide hours is not 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 an increase in home health aide services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an increase in home health aide services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs therapy at an IRF. The Plan 
denied your request. The Plan says the Medicare guidelines for IRF admission were not met and the enrollee 
can receive the services that they need in another setting like a skilled nursing facility (SNF). 
 
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 the enrollee is medically stable with no acute events and does not need physical 
medicine and rehabilitation physician's close supervision 3 times per week (at a minimum) for the ongoing 
management of any active or acute exacerbations of chronic medical conditions. There are no nursing needs 
documented. IRF is not indicated at the current functional level, the enrollee does not need 3 hours a day and 5 
days a week of therapies with multidisciplinary approach in an IRF. 
 
The documentation does not support medical necessity for admission to an IRF. The enrollee has no acute 
medical issues or complex medical problems, and no rehabilitation nursing needs other than routine nursing 
care. While the enrollee may benefit from physical therapy and occupational therapy, the enrollee's 
rehabilitation needs can be safely met in an alternate and low intensity setting such as in an SNF. 
 
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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prosthesis replacement and associated accessories to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve prosthesis replacement and associated accessories. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the requested items can be 
provided by 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 
prosthesis replacement and associated accessories 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 procedure code 86077 billed for date of service July 18, 
2022. 
 
You asked the Plan to pay for procedure code 86077. You say that these services were reported correctly. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service July 18, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (90832) provided to the enrollee on December 22, 2021.
You asked the Plan to pay for the psychotherapy services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says that rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, if attempts to consult did not succeed, that date and manner of notification to the physician. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have not been met. Specifically, the record does not include documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. Therefore, we decided that the Plan does not have to pay for the psychotherapy services (90832) provided to the enrollee on December 22, 2021.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found documentation shows that the enrollee has functional impairments, but no complex 
functional deficits are specified thus the enrollee would not be expected to require intense therapy or 
interdisciplinary team management of rehabilitation in an IRF setting. Clinical documentation shows that 
medical comorbidities are stable without active features per primary team documentation thus the enrollee 
would not be expected to require continued inpatient hospitalization during rehabilitation.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need physical therapy and occupational therapy 
more than 3 times per day. The Plan denied your request. The Plan says you do not meet Medicare guidelines 
for services in an IRF. 
 
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 there are no complex nursing or rehabilitation needs. While you may need 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Eyelea (J0178), injection (67028), and provision of 
supply and material by physician (99070) provided on March 31, 2022, by a foreign provider. 
 
You asked the Plan to pay for the physician services. You say that your coverage has not changed. You say that 
these services have been covered in the past. You also say that this should be paid. The Plan denied your 
request. The Plan says the services in this case were not urgent or emergent. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the physician services have not been met. Specifically, the file does not support that the services 
were urgent or emergent in nature. Therefore, we decided that the Plan does not have to pay for the Eyelea 
(J0178), injection (67028), and provision of supply and material by physician (99070) provided on March 31, 
2022, by a foreign provider.
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. 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 and 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. 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: 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 this enrollee meets medical necessity criteria for an 
inpatient rehabilitation facility (IRF) admission. The Plan denied your request. The Plan says the enrollee's 
condition does not meet Medicare guidelines for services in an IRF. 
 
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, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous transcatheter closure of congenital 
interatrial communication with implant (PFO procedure). 
 
You asked the Plan to pre-approve PFO procedure. You say that the enrollee's neurologist recommends closure 
of the PFO. The Plan denied your request. The Plan says this 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 PFO procedure. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the records do not show that the enrollee is less than 60 years old, does not have at least 28 days 
of monitoring showing no atrial fibrillation, and no recent imaging showing current and significant shunting as 
required to be considered for PFO surgical closure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PFO procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous transcatheter closure of congenital interatrial communication with implant 
(PFO procedure).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the pulpal debridement (D3221) for tooth #3. 
 
You asked the Plan to pre-approve the dental service. You say that the requested service is part of the 
treatment, and you would like the Plan to cover the dental service. The Plan denied your request. The Plan says 
that the denial of authorization for this service is correct, because the pulpal debridement is not covered by the 
Plan. 
 
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. The Plan did not submit the proper EOC to show if the requested dental service 
is or is not covered. This means that we cannot determine if the Plan was correct to deny the dental service. It is 
the burden of the Health Plan to substantiate their denial with evidence. In this case, the denial has not been 
substantiated so we must find in your favor. Therefore, we decided that the Plan has to pre-approve the pulpal 
debridement (D3221) for tooth #3.  
 
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 home ventilator, any type, used with non-invasive 
interface, (e.g., mask, chest shell) (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that please find attached additional documentation that 
show the enrollee meets the Medicare rules for the E0466. The Plan denied your request. The Plan says the 
enrollee does not appear to have the severity of illness that would justify the need for a home mechanical 
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 a ventilator. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this enrollee has severe COPD, although there are no PFTs for confirmation. There is no ABG 
done while stable to document chronic CO2 retention. If the patient does have chronic CO2 retention, may 
benefit from BiPAP with AVAPS during sleep. But Medicare does not cover a home ventilator when used as 
BiPAP. A home ventilator is not 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell) 
(E0466).