Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable and suitable for 
transfer to an LTACH. You also say LTACH services are necessary due to the enrollee's multiple 
comorbidities. The Plan denied your request. The Plan says the requested LTACH services do not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee appears to be improving but is still somewhat unstable and requires 
additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for transfer. There are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Transfer to the LTACH is not medically necessary as the enrollee 
is not yet stable and as it would not be clinically advantageous. Completion of treatment at the current facility 
is 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for procedure code J3490 billed for date of service July 7, 2022. 
 
You asked the Plan to pay for the billed service. You say that the drug was medically necessary. The Plan 
denied your request. The Plan says that code J3490 is included in the global surgery period for code 27096. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
In this case, the CPT Code Manual definition of code J3490 is unclassified drugs. We find that CPT code J3490 
is supported in the medical record. The billed code was submitted with a national drug code that coincides with 
the drug documented in the medical records. Code J3490 is not an evaluation and management service. The 
drug is separately payable in this case. The Plan has not provided a Medicare rule that would indicate the drug 
should be included in the global surgery package. Based on this information, we decided that Medicare rules 
for coverage of the billed service have been met. Therefore, we decided that the Plan has to pay for procedure 
code J3490 billed for date of service July 7, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D0120 and D1110) on October 24, 2022. 
 
You asked the Plan to pay for the dental services (D0120 and D1110). You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says your benefit for the requested 
services 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 requested item or service was exhausted on date of service April 12, 2022, and 
September 20, 2022. Therefore, we decided that the Plan does not have to pay for the dental services (D0120 
and D1110) on October 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bifocals, the progressive lens, the tint, the polycarbonate 
lens, the scratch resistant coating, and the frames provided on September 7, 2022. 
 
You asked the Plan to pay for the vision services. You say that you want the Plan to reimburse you $100 for the 
lenses. The Plan denied your request. The Plan says the provider is out-of-network.  
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when received in-network. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, 
we decided that the Plan does not have to pay for the bifocals, the progressive lens, the tint, the polycarbonate 
lens, the scratch resistant coating, and the frames provided on September 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 80307 billed for date of service September 
27, 2022. 
 
You asked the Plan to pay for procedure code 80307. You say that you would like the Plan to reconsider their 
denial of payment. 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 80307 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 80307 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 80307 billed for date of service September 27, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service August 24, 
2022. 
 
You asked the Plan to pay for procedure code 76642. You say that at least one unit is payable. 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 for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76642 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76642 billed for date of 
service August 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the precision attachments (D5862) provided on October 25, 
2022. 
 
You asked the Plan to pay for the dental services. You say that the dental procedure should be covered for a 
denture replacement, and you would like the Plan to pay the dental provider. The Plan denied your request. The 
Plan says the denial of payment for these services is correct, because the precision attachments are not covered 
by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  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 
precision attachments (D5862) provided on October 25, 2022.
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 would like to go to a specific facility. The Plan 
denied your request. The Plan says an IRF admission is not medically necessary, and you can safely receive the 
services you need in another setting. 
 
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 require intensive rehabilitation and frequent physician oversight. 
 
   
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: 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 you would like reconsideration because the services 
are medically necessary. The Plan denied your request. The Plan says a SNF admission is not medically 
necessary, and your needs can be safely met in an alternate setting. 
 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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing or skilled therapy on an inpatient basis in a 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83036 provided on February 16, 2022. 
 
You asked the Plan to pay for procedure code 83036. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 83036 is Hemoglobin; glycosylated (A1c). 
 
We find that CPT code 83036 is not supported in the medical record. Specifically, the laboratory report shows 
that this test was rejected and not completed. Based on this information, we decided that Medicare rules for 
coverage of procedure code 83036 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 83036 provided on February 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (A5500 and A5513) provided 
on November 11, 2021. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
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 proof of delivery for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for the durable medical equipment (A5500 and A5513) provided on 
November 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5298) purchased from an out-of-network 
(OON) provider on October 20, 2022. 
 
You asked the Plan to pay for the hearing aids. You say that hearing aids are covered under your plan. The Plan 
denied your request. The Plan says it was confirmed that you did make outreach to the Plan's hearing 
department prior to this date of service, and were referred to an in-network provider. The Plan also says that 
you received these hearing aids from an OON provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you use the Plan's approved hearing aid vendor to use your hearing aid benefits. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
the hearing aids (V5298) purchased from an out-of-network (OON) provider on October 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the guided tissue regeneration (D4266), the biopsy of oral 
tissue (D7285), the collection and application of blood concentrate (D7921), the bone replacement graft 
(D7953), and therapeutic drugs (D9610) for tooth #14 provided on July 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental services provided to the enrollee were 
medically necessary and coded properly. The Plan denied your request. The Plan says the denial of payment for 
these services is correct, because the guided tissue regeneration, the biopsy of oral tissue, the collection and 
application of blood concentrate, the bone replacement graft, and therapeutic drugs are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
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 
guided tissue regeneration (D4266), the biopsy of oral tissue (D7285), the collection and application of blood 
concentrate (D7921), the bone replacement graft (D7953), and therapeutic drugs (D9610) for tooth #14 
provided on July 18, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for billed code J3490 provided on September 16, 2022. 
 
You asked the Plan to pay for the billed services. You say that the drug was a necessary part of the enrollee's 
treatment. The Plan denied your request. The Plan says that code J3490 is included in the global surgery period 
for code 27096. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
In this case, the CPT Code Manual definition of code J3490 is unclassified drugs. We find that CPT code J3490 
is supported in the medical record. The billed code was submitted with a national drug code that supports the 
drug documented in the medical records. This drug is separately payable. The Plan has not provided a Medicare 
rule that would indicate the drug should be included in the global surgery package. Based on this information, 
we decided that Medicare rules for coverage of the billed services have been met. Therefore, we decided that 
the Plan has to pay for billed code J3490 provided on September 16, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says it is not 
medically necessary for the enrollee to be in an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our physician 
reviewer found that the enrollee does not require services at the LTACH that are not available at the acute care 
hospital where he/she is currently receiving care. All medically necessary care is being provided in the current 
acute care setting. The health plan has approved ongoing care in the current acute care setting. The requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the Electroencephalogram (EEG), continuous recording with 
interpretation and report (95720) provided on July 27, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plans 
denial for payment. The Plan denied your request. The Plan says that the service provided was not medically 
necessary for the enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 pay for this service. Our reviewer says that the 
service provided is considered medically reasonable and necessary in this case. Our physician reviewer found 
that in this case the enrollee had presented to the hospital for both an altered mental status and possible 
witnessed seizures. In such a clinical setting, particularly in the setting of suspected witnessed seizures, 
performance of an EEG would have been readily consistent with the generally accepted standards of 
practice/care. Such monitoring was done to rule in/out epilepsy or other neurological insult. This testing 
followed well defined standards of care. In as much, the service under review is considered to be reasonable 
and medically necessary for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have been met. Therefore, we decided that the Plan has to pay for 
the Electroencephalogram (EEG), continuous recording with interpretation and report (95720) provided on  
July 27, 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: 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 the enrollee's condition warrants required continued 
physician oversight of nursing and functional progress with physical therapy and occupational therapy for safe 
discharge to community. The Plan denied your request. The Plan says the submitted documentation does not 
support that the enrollee needs a physician rehabilitation specialist oversight every other day. 
 
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 the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. 
 
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.