Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on January 19, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the assisted living facility is 
responsible to obtain prior authorization for all of their patients, which should also cover for the medical 
treatments provided by this provider. The Plan denied your request. The Plan says this provider is out-of-
network with the Plan, and authorization was not obtained prior to the services being rendered. 
 
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 a domiciliary or rest home visit provided on 
January 19, 2022, 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 an admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says your needs can be met at a lower level of care. 
 
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 Our reviewer found that your medical problems are stable and there are no complex 
nursing or rehabilitation needs. While you have a need for physical or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for incontinence supplies provided on February 22, 2022. 
 
You asked the Plan to pay for incontinence supplies. You say that you have been receiving incontinence 
supplies since 2018 without any out of pocket expense, this was 100% covered. The Plan denied your request. 
The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pay for incontinence supplies provided on 
February 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) coded 70450 provided on 
January 30, 2022. 
 
You asked the Plan to pay for the computed tomography. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services billed are 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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the computed tomography (CT) coded 70450 provided on 
January 30, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission. You say that you feel that daily skilled therapy would allow 
you to return home. The Plan denied your request. The Plan says no daily skilled services are required. 
 
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 the admission. Our reviewer says that 
the requested admission is not medically reasonable or necessary. Our physician reviewer found you remained 
medically stable, and you do not require skilled nursing and/or skilled therapy services on a daily basis. You 
can receive further rehab services at a lower level of care. Although further rehabilitation services would be 
appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a 
lower level of care than a skilled nursing. In terms of skilled nursing, you do not have any parenteral 
medication, complex wound care, or nutrition given via a feeding tube. You are medically stable without any 
acute exacerbations of chronic medical problems. Your physical function is at or near baseline, and you can 
receive services in a lower level of care. Continued care in a SNF for inpatient skilled rehab services is not 
medically reasonable or 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 the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 12, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on April 12, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve addition, endoskeletal, knee-shin system, stance flexion feature, 
adjustable (L5845). 
 
You asked the Plan to pre-approve the endoskeletal, knee-shin system. You say that please see attached 
documentation for an appeal for denied left transfemoral prosthesis request. The Plan denied your request. The 
Plan says that L5845 cannot be used for this device and is unbundled. 
 
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 pre-approve the endoskeletal, knee-shin system. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the requested code L5845-addition, endoskeletal, knee-shin system, stance 
flexion feature, adjustable was noted to be justified. She will benefit from a prosthetic knee that incorporates a 
stance flexion feature (that provides shock absorption at heel strike by mimicking the flexed anatomical 
position of the knee at that state in the normal gait cycle.) This also improves stability when traversing low-
lying environmental barriers. Therefore, the medical records provided meet the requirements listed in the LDC 
for Medicare coverage and show that the items/services at issue, in this case, are medically reasonable and 
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 the endoskeletal, knee-shin system have been met. Therefore, we decided that 
the Plan has to pre-approve addition, endoskeletal, knee-shin system, stance flexion feature, adjustable 
(L5845).  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the breast ultrasound rendered on February 8, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The plan must follow Medicare rules. The rules say that anatomical modifiers are required for procedures 
performed on different anatomical sites. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with the required 
anatomical modifier. Therefore, we decided that the Plan does not have to pay for the breast ultrasound 
rendered on February 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214) provided by a 
participating provider. 
 
You asked the Plan to pre-approve a mandibular partial denture. You say that you need this because you had 
teeth extracted. The Plan denied your request. The Plan says the benefit limit for D5214 has already been 
exhausted. 
 
Medicare generally does not cover dental services. Evidence was provided to show that D5214 was previously 
provided on However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the 
Plan's coverage rules apply in this case. The Plan covers a mandibular partial denture once every five years. 
 
We looked at the file and Medicare rules. D5214 was previously provided on November 5, 2019. Based on this 
information, we decided that the Plan's rules for coverage of a mandibular partial denture have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture (D5214) 
provided by a participating provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI), of the pelvis; 
without contrast material(s), followed by contrast material(s) and further sequences. 
 
You asked the Plan to pre-approve this service. You say that an MRI of the pelvis is medically necessary for 
the enrollee. The Plan denied your request. The Plan says that this service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 pre-approve this service. Our reviewer says that an 
MRI of the pelvis is not medically necessary. Our physician reviewer found that in this case, there was no 
documentation of a Prostate-Specific Antigen (PSA) level and the Digital Rectal Examination (DRE) provided 
was normal. For the diagnosis of Prostate Cancer an MRI is indicated in any of the following scenarios: 
Persistent and unexplained elevation in a Prostate-Specific Antigen (PSA) level or a very suspicious Digital 
Rectal Examination (DRE), Initial staging of intermediate or high-risk prostate cancer, and Risk-stratification 
of low-risk cancer for potential active surveillance. The review has determined that the requested MRI is not 
medically reasonable or 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve magnetic resonance imaging (MRI), of the pelvis; without contrast material(s), followed 
by contrast material(s) and further sequences.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve services to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the services. The Plan denied your request. The Plan says the services are 
available in-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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve services to 
be provided by an out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services rendered on November 3, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that outpatient rehabilitation claims must include one of 
the GN, GO, or GP modifiers. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with the required GP 
modifier. 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 pay for the physical therapy services rendered 
on November 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a second pair of eyeglasses provided on May 24, 2021. 
 
You asked the Plan to pay for a second pair of eyeglasses. You say that the provider told you that both pair of 
eyeglasses would be covered. The Plan denied your request. The Plan says the second pair of glasses was 
denied as your benefit was already utilized. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
 We looked at the file and the Plan's rules. The file shows that your vision benefit was utilized. Based on this 
information, we decided that the Plan's rules for coverage of a second pair of eyeglasses have not been met. 
Therefore, we decided that the Plan does not have to pay for a second pair of eyeglasses provided on  
May 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic dental x-ray (code D0330) you had on 
February 15, 2022. 
 
You asked the Plan to pay for the panoramic dental x-ray. You say that you did not know about the frequency 
limit and you believe your dental services should be covered up to $4000 per year. The Plan denied your 
request. The Plan says you were not eligible for this service because you had exhausted the benefit. 
 
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. Under the Plan's rules, 
panoramic dental x-rays are covered once every three years.  Records show that you received a covered 
panoramic dental x-ray on February 24, 2021, so you would not be eligible for this service again until after 
February 24, 2024.  This restriction applies regardless of the reason for the x-ray. 
 
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 
panoramic dental x-ray (code D0330) you had on February 15, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services (81161, 81411, and 81238) provided on October 
19, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan denied payment for codes 81161, 81411, and 81238 stating, these 
codes are "inclusive to the 81439 as you are unable to bill for the individual components of the test." However, 
the Plan has provided no supporting evidence that shows these codes cannot be reported together for separate 
payment per Medicare guidelines. Therefore, we decided that the Plan has to pay for the laboratory services 
(81161, 81411, and 81238) provided on October 19, 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 pay for the periodontal scaling and root planing - four or more teeth 
per quadrant (D4341) provided February 8, 2022. 
 
You asked the Plan to pay for the periodontal scaling and root planing. You say that you would like this service 
covered. The Plan denied your request. The Plan says this service is not covered under your benefits. 
 
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 
periodontal scaling and root planing - four or more teeth per quadrant (D4341) provided February 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve center mount power elevating leg rest/platform, TRU-
balance 3 configuration, transit kit, privacy flap, TRU-balance 3 armrest, and non-retractable lap belt. 
 
You asked the Plan to pre-approve center mount power elevating leg rest/platform, TRU-balance 3 
configuration, transit kit, privacy flap, TRU-balance 3 armrest, and non-retractable lap belt. You say that you 
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items 
are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The rules say that elevating leg rests are covered when the enrollee has a musculoskeletal 
condition or the presence of a cast or brace which prevents 90-degree flexion at the knee or the enrollee has 
significant edema of the lower extremities that requires an elevating legrest or the enrollee meets the criteria for 
and has a reclining back on the wheelchair. The rules also say that there is no separate billing/ payment if fixed, 
swingaway, or detachable non-adjustable height armrests with arm pad are provided. 
 
The documentation does not support that the enrollee has a musculoskeletal condition or the presence of a cast, 
or brace which prevents 90-degree flexion at the knee, or there is no significant edema of the lower extremities, 
and there is no request for a reclining back on the requested power wheelchair. Therefore, the enrollee does not 
meet criteria for the requested elevating leg rest. 
 
The requested Tru-balance 2 configuration is a seat frame system. This requested item exceeds the enrollees 
needs and is not supported. There is no provided clinical documentation that indicates that the enrollee requires 
a seat width and/or depth greater than 20 inches, and the enrollee's weight is documented as 160 pounds which 
is well under the capacity of the requested power wheelchair. 
 
The requested transit kit at issue in this appeal does not serve a purpose that is primarily medical in nature. This 
item is available to the general public and would be helpful even to those who are not sick or injured.  
The requested privacy flap is non-covered. 
 
There is no separate billing of armrests as the requested armrests exceed the enrollees needs. Therefore, this 
item is considered unbundled and therefore, not covered. 
 
The requested lap belt is non-covered as the requested power wheelchair already comes with a seat belt. 
 
Therefore, we decided that the Plan does not have to pre-approve center mount power elevating leg 
rest/platform, TRU-balance 3 configuration, transit kit, privacy flap, TRU-balance 3 armrest, and non-
retractable lap belt.