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

 
We decided that the Plan does not have to pre-approve esophagogastroduodenoscopy (EGD) (43239). 
 
You asked the Plan to pre-approve an EGD. You say that the enrollee has experienced a recurrence of vocal 
cord lesions since his last EGD and follow up testing is medically necessary. The Plan denied your request. The 
Plan says the requested test is not medically necessary. The enrollee has already had a test like this, and the 
results are included in the medical record. This prior study showed the necessary information to proceed with 
treatment. Repeat testing is not supported without results of prior testing that show a clear reason for it. 
 
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 an EGD. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found he record indicates that the enrollee underwent an esophagogastroduodenoscopy in March 2021 
and was found to have reflux. The record indicates that the enrollee was successfully treated with proton pump 
inhibitors. The record indicates that the enrollee has vocal cord lesions considered secondary to reflux. The 
record does not indicate that the enrollee has failed therapy for a known diagnosis. The elements of the 
coverage rules are not satisfied; the requested service cannot be recommended.  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 EGD have not been met. Therefore, we decided that the Plan does not have 
to pre-approve esophagogastroduodenoscopy (EGD) (43239).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee on November 1, 2020, to November 15, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider has reported skilled services with the incorrect PDPM Health Insurance Prospective 
Payment System (HIPPS) Score. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
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 the documentation is insufficient to 
support that the enrollee was receiving parenteral/IV feeding on 10/24/2020 or 10/25/2020. 
 
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 skilled nursing facility (SNF) services provided to the enrollee on November 1, 2020, to 
November 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of bone marrow aspirate in the 
setting of spinal fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Bone marrow 
aspirate is experimental. More research is needed to show safety and efficacy. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bone marrow aspirate for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation and periapical x-rays (D0140 and 
D0220) provided on December 23, 2021. 
You asked the Plan to pay for the limited oral evaluation and periapical x-rays. You say that you would like 
reconsideration for payment. The Plan denied your request. The Plan says these services are not covered under 
your dental 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 pay for the 
limited oral evaluation and periapical x-rays (D0140 and D0220) provided on December 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis 
(D1110) provided on December 30, 2021. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you were not notified 
that your plan only allowed one cleaning per year and not two. The Plan denied your request. The Plan says 
your benefits for these services have been satisfied and the frequency limitations have been exceeded. 
 
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, periodic oral exam and prophylaxis 
(cleaning) are limited to up to 1 per year. The record shows that you received a periodic oral evaluation 
(D0120) and prophylaxis (D1110) on May 25, 2021 and your periodic oral exam and prophylaxis benefits have 
been exhausted. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation 
(D0120) and prophylaxis (D1110) provided on December 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care related to a knee 
arthroplasty procedure. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the requested inpatient care is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for 
inpatient admission have not been met. 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found that detailed documentation is not evident in the case record regarding 
current/significantly active medical conditions that would place the enrollee at increased risk for peri-surgical 
complications requiring necessary hospital care (including earlier ED and/or observation care) that would span 
two midnights. The preoperative consult indicates that the enrollee is at low risk for complications from knee 
replacement. Moreover, the plan is for the enrollee to go to a skilled nursing facility post-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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care related to a knee arthroplasty procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nuvasive Osteocel allograft for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of the Nuvasive Osteocel 
Allograft in the setting of spinal fusion surgery has not been demonstrated in the peer-reviewed literature. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. There is limited 
published, large-scale, long-term peer-reviewed literature that shows this request to be an effective and/or safe 
treatment for the enrollee's pathology.  
There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception to guidelines. Our physician reviewer found that the enrollee's condition does 
not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Nuvasive Osteocel allograft for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the periodic oral evaluation (D0120), 
intraoral periapical x-rays (D0220 and D0230), bitewings (D0274) and periodontal scaling and root planing 
(D4341) provided on January 19, 2022.  
You asked the Plan to waive the cost share for the periodic oral evaluation, intraoral periapical x-rays, 
bitewings and periodontal scaling and root planing. You say that you would like reconsideration because you 
did not know that your coverage had changed. The Plan denied your request. The Plan says the cost sharing for 
these services has been applied correctly. 
 
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. 
 
We looked at your request, the file and Plan rules. You have been asked to pay a 0% coinsurance for the 
periodic oral evaluation, 1 periapical x-ray and bitewings. You have been asked to pay a 70% coinsurance for 
the root planing and scaling. The coinsurance for these services has been applied correctly. Additionally, the 
Plan limits coverage to 1 periapical x-ray per year. You are responsible for payment of the second periapical x-
ray as this benefit has been exhausted. Therefore, we decided that the Plan does not have to waive the cost 
share for the periodic oral evaluation (D0120), intraoral periapical x-rays (D0220 and D0230), bitewings 
(D0274) and periodontal scaling and root planing (D4341) provided on January 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the injection provided on December 9, 
2021. 
 
You asked the Plan to waive the copayment for the injection. You say that the injection was given just one 
floor up from your orthopedic doctor's office and there was no way a patient could tell they were entering a 
separate hospital facility. The Plan denied your request. The Plan says the copayment applied correctly. 
 
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 a $250 
copayment for each in-network Medicare-covered outpatient hospital service. You have been asked to pay $250 for your injection. Your injection falls within the Outpatient hospital 
services benefit category. 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 the injection provided on 
December 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on December 27, 2021. 
 
You asked the Plan to pay for lab test. You say that you are appealing with supporting records. The Plan denied 
your request. The Plan says the denial of payment for this testing is correct, because this testing is not covered 
for screening purposes. 
 The Plan must follow Medicare rules. Medicare rules say that a physician order or authenticated medical record 
showing clear intent to order specific lab services is required for covered lab services.  
 
We looked at the file and Medicare rules. The record does not include a physician order or clear intent to order 
the specific lab service billed on this claim. Based on this information, we decided that Medicare rules for 
coverage of lab test have not been met. Therefore, we decided that the Plan does not have to pay for laboratory 
testing provided on December 27, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
October 23, 2021. 
 
You asked the Plan to waive the copayment for an ER visit. You say that you should not be responsible for this 
copayment because you only went to the ER for blood work. The Plan denied your request. The Plan says you 
have been charged the correct cost sharing amount. 
 
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 a $90 
copayment for an emergency room visit.  
 
The medical record shows you had an emergency room visit on October 23, 2021. You have been asked to pay 
a $90 copayment for an ER visit. An ER visit falls within the Emergency Care benefit category. 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 an emergency room (ER) visit provided on October 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic radiology procedures of the upper extremities 
provided on October 26, 2021. 
 
You asked the Plan to pay for diagnostic radiology procedures of the upper extremities. The Plan denied your 
request. The Plan says the services were not urgent or emergent. It was also determined the services rendered 
could have been provided by a participating provider under the members Plan. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for diagnostic radiology procedures of the upper extremities 
provided on October 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2313, E2377), calf panels 
and arm pads (K0108, K0019) for a power wheelchair. 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that these items are medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met for the requested 
accessories. 
 The Plan follows Medicare rules. Medicare rules say that expandable controllers are covered when medically 
necessary. Code K0019 is for replacement items only. These codes are not used at the time of initial issue. 
 
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 wheelchair accessories. Our 
reviewer says that the requested items are not medically necessary. Our physician reviewer found the requested 
accessories are not medically necessary as the enrollee does have use of his hand and can operate and control 
the power options using the switches that are included in the basic wheelchair. The arm pads and calf panels 
are included in the base wheelchair and are not eligible to be separately billed. 
 
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 wheelchair accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an expandable controller (E2313, E2377), calf panels and arm pads (K0108, 
K0019) for a power wheelchair.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the testing and specimen handling fee. We decided that the Plan does 
not have to pay for the handling coded 99000.  
 
You asked the Plan to pay for the testing and specimen handling fee. You say that it is felt that these services 
are medically necessary and should be paid. The Plan says that code G0483 cannot be appealed, and code 
99000 is not separately payable. 
 
We decided that the Plan has to pay for the drug testing coded G0483.  
 
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 code was denied on December 6, 2021, for requested information not being received. That such 
information was received as an appeal request would not exempt the code from an appeal determination. Since 
the Plan forfeited the opportunity to provide a valid denial rationale, we find that the denial is not substantiated. 
Therefore, we decided that the Plan has to pay for the drug testing coded G0483.  
 
We also decided that the Plan does not have to pay for the handling coded 99000. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99000 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99000 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the handling fee have not been met. Therefore, we decided that the Plan does not have to pay for the 
handling coded 99000. 
 
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 the x-ray services provided on November 10, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the x-ray services. You say that you are a mobile imaging provider, and you have 
no way of knowing what insurance the enrollee has or if an authorization is needed. The Plan denied your 
request. The Plan says the rendering and referring providers are both out-of-network providers and there was 
no approved authorization. Also, the service rendered was not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the x-ray services provided on November 10, 
2021, by an out-of-network (OON) provider.
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 IRF care is medically reasonable and necessary. The 
Plan denied your request. The Plan says rules for IRF care have 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 the patient was admitted for altered mental status and possible seizure. Medical 
problems are stable. There are no complex nursing or rehabilitation needs.   
The patient does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not 
a reasonable expectation that this patient 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.