Persius/hicric huggingface dataset:
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 limited documentation does not support that you are stable for transfer to an IRF. 
The documentation does not support that you require at least three (3) hours a day, five (5) days a week, or 
fifteen (15) hours over seven (7) consecutive days, of therapy services. Based on the available clinical 
documentation, there is not a reasonable expectation that you will be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an IRF.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy (S9338, 99602 and 99601) 
provided on September 2, 2021. 
 
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says CPT codes S9338, 99602 and 99601 have a 
status indicator of I. 
 
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 codes S9338, 99602 and 99601 are not supported in the record. Specifically, CPT codes 
S9338, 99602 and 99601 have a status indicator of I. This means that CPT codes S9338, 99602 and 99601 are 
not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the 
home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for the 
home infusion therapy (S9338, 99602 and 99601) provided on September 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer device. 
 
You asked the Plan to pre-approve the Vertiflex Superion Spacer device. You say that you would like 
reconsideration because the requested procedure is medically necessary. The Plan denied your request. The 
Plan says this procedure is considered experimental. 
 
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 the Vertiflex Superion Spacer device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found FDA contraindications include spinal instability, scoliosis, obesity, and 
osteoporosis, and have not been adequately addressed in the medical records. There is no discussion of spinal 
instability on flexion/extension films. X-rays were noted to show an 18-degree levoscoliotic curvature as well 
as degenerative disc disease on multiple levels. There is no discussion indicating that a DEXA scan has 
demonstrated the lack of significant osteoporosis in this member. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. 
 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 Vertiflex Superion Spacer device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the Vertiflex Superion Spacer device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (73600) provided on July 13, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
billed with an appropriate modifier. 
 
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 73600 is not supported in the medical record. Specifically, an appropriate anatomical 
modifier was not billed. 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 the services (73600) provided 
on July 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Movantik 25 mg tablet. 
 
You asked the Plan to pre-approve Movantik. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-
administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the 
requested drug is not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Movantik 25 mg tablet.  
 Benefits for Movantik may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia (99100) provided on July 5, 2021. 
 
You asked the Plan to pay for the anesthesia (99100). You say that the claim was incorrectly denied and there 
is no reason the claim should not result in payment. You say the claim was billed correctly and the medical 
records support the appeal. The Plan denied your request. The Plan says bundled services are not eligible for 
separate reimbursement. 
 
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 99100 is anesthesia for patient of extreme age, younger 
than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure). 
 
  We find that CPT code 99100 is not supported in the medical record. Specifically, CPT code 99100 has a status 
indicator of B. This means that CPT code 99100 is considered bundled and not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the anesthesia (99100) have not been met. 
Therefore, we decided that the Plan does not have to pay for the anesthesia (99100) provided on July 5, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic activities provided on September 25, 2021. 
 
You asked the Plan to pay for therapeutic activities. You say that medical records were sent for review. The 
Plan denied your request. The Plan says an appeal was submitted by the provider with no new medical records. 
Documentation submitted on appeal consists of duplicates of medical documents previously reviewed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment.   
 
 
 We looked at the file and Medicare rules. The file shows that you did not submit sufficient medical documents 
to justify payment of the claim. Therefore, we decided that the Plan does not have to pay for therapeutic 
activities provided on September 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pharmacogenetic panel (81230, 81240, 
81241, 81249, 81291, 81408) provided on July 20, 2021. 
 
You asked the Plan to pay for a pharmacogenetic panel. You say that this testing is supported in the records. 
The Plan denied your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that if a laboratory assays 2 or 
more genes in a patient in parallel, then those 2 or more genes will be considered part of the same panel. A 
panel constitutes a single procedural service, so 1 code must be submitted for the panel. 
 
We find that CPT codes 81230, 81240, 81241, 81249, 81291, and 81408 are not supported in the medical 
record. Specifically, these codes were used to report a panel, which should be billed with 1 code. Based on this 
information, we decided that Medicare rules for coverage of a pharmacogenetic panel have not been met. 
Therefore, we decided that the Plan does not have to pay for a pharmacogenetic panel (81230, 81240, 
81241, 81249, 81291, 81408) provided on July 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the contact lenses (V2520, V2523) provided on November 2, 
2021. 
 
You asked the Plan to pay for the contact lenses. You say that these services should be covered. The Plan 
denied your request. The Plan says the cost of the contact lenses has been paid up to the $200 annual benefit 
limit, and you are responsible for the remaining cost. 
 
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 up to $200 per calendar year. 
 
We looked at the file and the Plan's rules. The Plan has paid the full $200 benefit allowance for these services, 
and you have been asked to pay the remaining cost for the contacts. This means that you have been asked to 
pay the correct amount for these services based on your contract with the Plan. Therefore, we decided that the 
Plan does not have to pay for the contact lenses (V2520, V2523) provided on November 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6533 
purchased on May 26, 2021. 
 
You asked the Plan to pay for these compression stockings. You say that these compression stockings were 
needed for lymphedema after Covid. The Plan denied your request. The Plan says these compression stockings 
are not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6533 purchased on May 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 6, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. 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. The AY modifier is used 
when the lab services are not related to ESRD. In this case there is no modifier to indicate this would be 
separate from ESRD. The medical records also indicate that these lab services were related to ESRD. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on May 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from July 26, 2020, through 
August 3, 2020 with the primary diagnosis code, R251 Tremor, unspecified. 
 
You asked the Plan to pay for the inpatient services with the primary diagnosis code, R251 Tremor, 
unspecified. The Plan denied your request. The Plan says during the audit of this claim, full medical records 
were requested and not provided and therefore, the claim was partially denied. Upon appeal, the full medical 
records was not provided after multiple attempts to obtain. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment.   We looked at the file and Medicare rules. The file shows that you did not submit sufficient medical documents 
to justify payment of the claim as billed. Therefore, we decided that the Plan does not have to pay for inpatient 
services provided from July 26, 2020, through August 3, 2020 with the primary diagnosis code, R251 Tremor, 
unspecified.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dermatology treatment provided on August 27, 2021 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dermatology treatment. You say that you would like reconsideration because 
there were no network providers that render your necessary treatment. The Plan denied your request. The Plan 
says you self-referred for these services which were not urgent, emergent or approved in advance. 
 
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 dermatology treatment provided on August 27, 
2021 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 comprehensive periodontal evaluation (D0180) provided 
on October 19, 2021. 
 
You asked the Plan to pay for the comprehensive periodontal exam. You say that this service was necessary for 
your oral health and should be covered. The Plan denied your request. The Plan says this service is not covered 
by 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 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 
comprehensive periodontal evaluation (D0180) provided on October 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture, initial 15 minutes (97813) acupuncture, 
each additional 15 minutes (97814) provided August 11, 2021 to October 11, 2021. 
 
You asked the Plan to pay for the acupuncture services. You say that you request that after reviewing the 
attached medical records that all services be reprocessed and paid. The Plan denied your request. The Plan says 
the services were rendered by a non-covered provider type. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the health Plan contract says the service must be 
provided by a legally qualified physician practicing within the scope of their license. The services were 
rendered by a licensed acupuncturist, not a physician. Therefore, we decided that the Plan does not have to pay 
for the acupuncture, initial 15 minutes (97813) acupuncture, each additional 15 minutes (97814) provided 
August 11, 2021 to October 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from June 
12, 2020, to June 18, 2020. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says payment of DRG remains not supported, as a review of the records supports DRG 101.  
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 DRG 100 (SEIZURES WITH MCC). 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our physician reviewer found the documentation 
throughout this hospital stay does not support acute respiratory failure. The documentation states that the 
enrollee was intubated to protect the airway related to seizures. Although acute respiratory failure is 
documented with other diagnosis codes, documentation does not support respiratory distress or inadequate 
respiratory effort.  
 
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 to the enrollee from June 12, 2020, to June 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral exam (D0120) and prophylaxis (D1110) 
provided on November 9, 2021. 
 
You asked the Plan to pay for the dental service. You say that it was your understanding that you are entitled to 
2 cleanings per year. You also say that this claim was denied. The Plan denied your request. The Plan says the 
frequency limits 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and the services are listed as covered, 
the frequency limits have been exceeded. The record shows that 2 oral exams are covered per plan year and 2 
prophylaxes are covered per plan year. The record also shows that the Plan paid for these services that you received on April 23, 2021, and July 22 ,2021. Therefore, we decided that the Plan does not have to pay for the 
periodic oral exam (D0120) and prophylaxis (D1110) provided on November 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve knee joint replacement surgery to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied 
your request. The Plan says that these services can be provided at a network facility. 
 
  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 
knee joint replacement surgery to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ,psychotherapy visits provided on January 12, 2021, to 
November 16, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy visits. You say that you are appealing the denied 
reimbursement requests. You say you have been seeing this provider for ten years. The Plan denied your 
request. The Plan says no prior authorization was obtained. 
 
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 
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 ,psychotherapy visits provided on January 12, 
2021, to November 16, 2021, by an out-of-network (OON) provider.