Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue generation (D4266), a complete upper 
denture (D5110), implants (D6010), implant supported crown (D6065), bone grafts (D6104), and radiographic 
surgical implant (D6190) for tooth #19 and #29. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denied dental 
services. The Plan denied your request. The Plan says your benefit for the complete upper denture has already 
been exhausted. The denial of authorization for the guided tissue generation, implants, implant supported 
crown, bone grafts, and radiographic surgical implant is correct, because they 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, certain limitations apply. The record 
shows your benefit for the complete upper denture was exhausted on the date of service of November 11, 2021. 
The guided tissue generation, implants, implant supported crown, bone grafts, and radiographic surgical 
implant are not covered under the Plans dental benefit. Therefore, we decided that the Plan does not have to 
pre-approve guided tissue generation (D4266), a complete upper denture (D5110), implants (D6010), implant 
supported crown (D6065), bone grafts (D6104), and radiographic surgical implant (D6190) for tooth #19 and 
#29.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 13, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 lab 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 lab services provided on September 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3 sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre 3 sensor. You say that the requested device is necessary to 
monitor your blood sugar. This system monitors blood sugar every minute versus every 5 minutes. You are 
single and live alone, so this device is lifesaving. The Plan denied your request. The Plan says the Freestyle 
Libre 3 sensor does not meet the definition of a therapeutic CGM as defined in CMS Ruling 1682R and is 
therefore non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that CGM devices that solely display results on a 
smartphone and do not have a stand-alone receiver or integration into an insulin infusion pump do not meet the 
definition of DME and will be denied as non-covered (no benefit). 
 
We looked at the file and Medicare rules. The local coverage article confirms that a CGM device that solely 
displays results on a smartphone and does not have a stand-alone receiver or integration into an insulin infusion 
pump, does not meet the definition of DME. The sensor is therefore not covered. Based on this information, we 
decided that Medicare rules for coverage of a Freestyle Libre 3 sensor have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Freestyle Libre 3 sensor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a water circulating heat pad with pump (E0217). 
 
You asked the Plan to pre-approve a water circulating heat pad with pump. You say that you will be having 
shoulder surgery on 1/19/2023. This will help you stay mobile for your after-surgery rehab. The Plan denied 
your request. The Plan says the requested item is not reasonable and necessary compared to a standard electric 
heating pad. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The LCD says that the requested item will be denied as not 
reasonable and necessary and therefore, not a covered benefit with your Plan. Based on this information, we 
decided that Medicare rules for coverage of a water circulating heat pad with pump have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a water circulating heat pad with pump 
(E0217).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 73502 billed for date of service June 13, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the enrollee had 2 x-rays done on the same date. 
The Plan denied your request. The Plan says the modifier and diagnosis are contradictory. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
In this case, the CPT Code Manual definition of code 73502 is radiologic examination, hip, unilateral, with 
pelvis when performed; 2-3 views. CPT code 73502 was billed with diagnosis code T84.021A, dislocation of 
internal left hip prosthesis.  We find that there is a more appropriate diagnosis code to describe services provided to the right hip. Based on 
this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 73502 billed for date of service June 13, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code T2003 billed for date of service July 19, 
2022. 
 
You asked the Plan to pay for procedure code T2003. You say that the enrollee was receiving minimal care in 
the hospital. You say that they were moved to a hospice facility. You say that the enrollee needed medical help 
and a stretcher. You also say that the transport was medically necessary. The Plan denied your request. The 
Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code T2003 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code T2003 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code T2003 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code T2003 billed for date of service July 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 20610-LT billed for August 11, 2022. 
 
You asked the Plan to pay for code 20610-LT. The Plan denied your request. The Plan says the claim was paid 
correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that if any of the multiple surgeries are bilateral 
surgeries, consider the bilateral procedure at 150 percent as one payment amount, rank this with the remaining 
procedures, and apply the appropriate multiple surgery reductions 
 We find that payment for CPT code 20610-LT is not supported in the medical record. Specifically, this 
procedure was performed as a bilateral surgery. The Plan paid 150 percent of the allowed rate for code 20610-
XS-RT. This means that the claim has been paid correctly by the Plan according to Medicare rules, and 
separate payment for code 20610-LT cannot be made. Based on this information, we decided that Medicare 
rules for coverage of code 20610-LT have not been met. Therefore, we decided that the Plan does not have to 
pay for code 20610-LT billed for August 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Optimizer Smart permanent cardiac contractility 
modulation (CCM) system. 
 
You asked the Plan to pre-approve Optimizer Smart. You say that the denial for this procedure is unwarranted 
and unsupported. The Plan denied your request. The Plan says this procedure 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 Optimizer Smart. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found current medical literature pertaining to the cardiac contractility modulation (CCM) 
system confirms studies suggesting clinical benefit. However, CCM remains the subject of multiple studies 
examining long-term efficacy as well as trials to quantify clinical efficacy. Until such statistically rigorous 
studies are completed, it is premature to presume clinical outcomes and benefits. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Optimizer Smart have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Optimizer Smart permanent cardiac contractility modulation (CCM) system.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on May 23, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that the lab services were 
medically necessary. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-
related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on May 23, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an injection of Inclisiran (Leqvio) (J1306). 
 
You asked the Plan to pre-approve an injection of Inclisiran (Leqvio). You say that this drug is medically 
necessary. The Plan denied your request. The Plan says this drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 injection of Inclisiran (Leqvio). Our 
reviewer says that this drug is not medically necessary. Our physician reviewer found all reported studies of 
Leqvio for ASCVD and cholesterol in the Medicare-approved major drug compendia required that patients had 
an LDL-cholesterol of at least 70 mg/dL (1.8 mmol/L). The patient in this case already has an LDL-cholesterol 
less than 70 mg/dL and thus does not meet criteria for the requested drug.  
 
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 injection of Inclisiran (Leqvio) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an injection of Inclisiran (Leqvio) (J1306).
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. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 there is no evidence that the enrollee requires services that are not currently available. 
The enrollee can remain at the current facility until such time no acute services are required. The enrollee can 
then be transferred/discharged to a lower level of care for any ongoing long-term care needs. 
 
   
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on June 18, 2021, to 
June 21, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that these 
services were reported appropriately and are supported as billed. The Plan denied your request. The Plan says 
the DRG billed on this claim is not supported by the medical records provided. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with sepsis, unspecified organism (A41.9). 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 the inpatient hospital services at the DRG originally billed. 
Our reviewer says that this diagnosis is not supported in the medical record. Our physician reviewer found that 
the enrollee was treated in the hospital with pneumonia and chronic obstructive pulmonary disease (COPD) 
exacerbation. The provided records described the enrollee as hemodynamically stable following initial 
treatment with normal liver, kidney and platelet. He had an elevated respiratory rate, but no arterial blood gas 
(ABG) results were found. There was no evidence of acute mental status changes. There was insufficient 
evidence provided showing there was sepsis based on the Sepsis 3 criteria which requires Sequential Organ 
Failure Assessment (SOFA) of 2+ and signs of a dysregulated response to the infection causing direct organ 
damage without other cause of the abnormalities. Therefore, the diagnosis of sepsis is not supported in the 
documentation.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on June 18, 2021, to June 21, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36000 billed for date of service June 1, 2022. 
 
You asked the Plan to pay for procedure code 36000. The Plan denied your request. The Plan says procedure 
code 36000 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 We find that procedure code 36000 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 36000 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
36000 billed for date of service June 1, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit. 
 
You asked the Plan to pre-approve Retacrit. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Retacrit. Our reviewer says that this 
drug is not medically necessary. Our physician reviewer found the medical records do not document a 
hemoglobin less than 10 g/dL or a transferrin saturation of at least 20% and ferritin level of at least 100 mcg/L 
as required by the Medicare-approved major drug compendia for the safe and effective use of Retacrit. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341, 88342, 88360, and 88381 billed for 
date of service February 4, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the rules for 
payment have not been met. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
The records indicate that this service was provided to the enrollee while an outpatient. Per the Physician Fee 
Schedule, there is a Professional/Technical indicator of 1 for CPT codes 88341, 88342, 88360, and 88381. This 
means there is both a professional and technical component for the CPT codes. In this case, an appropriate 
modifier to indicate the professional component has not been billed with the CPT codes. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure codes 88341, 88342, 88360, and 88381 billed for date of service 
February 4, 2022.
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. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct. 
 
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 the enrollee does not require services at the LTACH that are not available at the 
current acute care hospital. The enrollee is receiving appropriate care at the current hospital. 
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve a cardiac stress test to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the cardiac stress test. The Plan denied your request. The Plan says this 
request cannot be approved as the request is non-emergent and there are in-network facilities available. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a cardiac stress test to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction provided on February 14, 2022. 
 
You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says the eye refraction 
is not a covered benefit since it was performed with a medical diagnosis. 
 
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 eye refractions when they are performed during a routine exam. 
 
We looked at the file and the Plan's rules. Specifically, the record shows that you were seen for a diagnosis of 
type 2 diabetes mellitus with mild no proliferative diabetic retinopathy with macular edema, left eye, presence 
of intraocular lens, vitreous degeneration, right eye, and puckering of macula, right eye, and combined forms of 
age-related cataract, bilateral for the eye refraction. This visit was medical based, and not a routine exam. 
Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been 
met. Therefore, we decided that the Plan does not have to pay for the eye refraction provided on February 14, 
2022.