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

 
We decided that the Plan does not have to pay for bone replacement grafts (D4263, D4264) provided on May 6, 2022. 
 
You asked the Plan to pay for replacement grafts. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says bone replacement grafts (D4263, D4264) are not covered by your 
dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for bone 
replacement grafts (D4263, D4264) provided on May 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray (D0220) provided on May 27, 2022. 
 
You asked the Plan to pay for an x-ray. You say that you called prior to the appointment to verify coverage. 
The Plan denied your request. The Plan says an intraoral x-ray (D0220) is not covered by your supplemental 
dental 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 an 
intraoral x-ray (D0220) provided on May 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an excision or curettage of bone cyst or benign tumor of 
femur; with autograft (includes obtaining graft) in addition to right knee arthroplasty (procedure code 27357) 
provided to the enrollee on January 12, 2022. 
 
You asked the Plan to pay for the services. You say that the 59 modifier was used appropriately and should 
have unbundled this service. The Plan denied your request. The Plan says the medical records do not support 
the usage of the 59 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 asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found that the operative report describes a 
total knee replacement, with excision of bone cyst and bone graft performed on the right knee. In this case, 
excision of bone cyst documented in the operative report would not be billed separately from the primary 
procedure, right knee arthroplasty. Modifier 59 is not supported, as this procedure would be performed in 
addition to the right knee arthroplasty.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for an excision or curettage of bone cyst or benign tumor of femur; with autograft (includes 
obtaining graft) in addition to right knee arthroplasty (procedure code 27357) provided to the enrollee on 
January 12, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services provided from April 5, 2021, to April 29, 2021. 
 
You asked the Plan to pay for the home health services. You say that this claim is marked as paid per Medicare 
allowable, but the claim has never been paid. The Plan denied your request. The Plan says that this claim is a 
duplicate. 
 
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. Specifically, the Plan's sole rationale for denial is that this claim is a duplicate.  
However, the original claim that you submitted wasn't paid either.  The Plan has provided no evidence that it 
has paid for these services, so they have not supported their denial based solely upon the argument of a 
duplicate submission. Therefore, we decided that the Plan has to pay for home health services provided from 
April 5, 2021, to April 29, 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 tooth extraction (D7140) provided on March 30, 2022 
 
You asked the Plan to pay for the tooth extraction. You say that you were not aware this was not a covered 
service, and were advised by your provider that extraction was the only option. The Plan denied your request. 
The Plan says tooth extraction (D7140) is not covered under your supplemental 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 tooth 
extraction (D7140) provided on March 30, 2022
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 49010 billed for date of service February 17, 
2022. 
 
You asked the Plan to pay for procedure code 49010. The Plan denied your request. The Plan says no modifiers 
are allowed with this code pair. 
 
  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 49010 
is a column II code to column I code 50650 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 49010 billed for date of service February 17, 2022.
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 since you have an open wound and need three 
different services, this would best fit so that you can be seen by all. The Plan denied your request. The Plan 
says the criteria for admission to the IRF setting has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there is not a reasonable expectation that this patient will be able to fully participate 
in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
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 you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of authorization for IRF care is correct. 
 
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 need intensive therapies consisting of at least 3 hours of therapy 
per day for at least 5 days per week with a multidisciplinary approach. While the enrollee may benefit from continued physical and/or occupational therapy, the enrollee's needs can be met in a lower level of care such as 
skilled nursing facility. 
 
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: 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 enrollee is suitable for transfer to the 
LTACH and their needs cannot be met at a lower level of care. The Plan denied your request. The Plan says the 
denial of authorization for LTACH care 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 appears to be stable and improving, and should only require short-term 
additional acute care services that can be safely administered at the current facility until more appropriate for a 
lower level of care. The enrollee does not require services at the LTACH that are not available at the current 
facility. 
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home health aide (HHA) for assistance with cooking, 
dressing, and light housekeeping. 
 
You asked the Plan to pre-approve an HHA. You say that you are having carpal tunnel surgery, and do not 
have anyone at home to assist you. The Plan denied your request. The Plan says Medicare does not cover 
custodial care. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a HHA have not been met. Specifically, we find that the services at issue in this case are 
considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve a home health 
aide (HHA) for assistance with cooking, dressing, and light housekeeping.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 36 additional trips. 
 
You asked the Plan to pre-approve 36 additional trips. You say that you need additional trips for future 
appointments. The Plan denied your request. The Plan says you have exceeded your benefit limit for routine 
transportation. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 36 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 36 additional trips.
Appeal type: Practitioner Services
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 February 14, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. 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 
February 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a battery backup (E1399). 
 
You asked the Plan to pre-approve a battery backup. The Plan denied your request. The Plan says this item is 
not covered by Medicare, nor is it covered under your plan. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
You are requesting a battery backup for your continuous positive airway pressure (CPAP) machine. A battery 
backup is considered duplicative, and therefore not covered. Therefore, we decided that the Plan does not have 
to pre-approve a battery backup (E1399).
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 February 14, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. 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 February 14, 2022.
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 services requested are medically 
necessary. The Plan denied your request. The Plan says the services requested are not medically necessary and 
criteria for LTACH haven't been met. 
 
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 medical record does not indicate that the enrollee requires services that they are 
not currently receiving. The enrollee still requires acute care services before transitioning to a lower level of 
care. 
 
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: 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 the enrollee's medical management and rehabilitation 
needs require an IRF. The Plan denied your request. The Plan says the criteria for admission to an IRF are not 
met. The enrollee can safely receive the necessary services in a less intensive 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 the complexity of the enrollees nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollees medical conditions appear stable on outpatient medications with no issues which would appear to 
require a physicians evaluation three or more times per week. Although the records support that the enrollee 
requires physical and occupational therapy services, the records do not clarify why the enrollee requires these 
services as part of an intensive inpatient rehabilitation therapy program provided only in an IRF rather than in a 
lower level of care. Based on the medical records provided there is no support in the documentation that the 
enrollee requires the intensive medical care and the intensive rehabilitation therapy program provided in an 
inpatient rehabilitation facility. The medical records do not clarify that treatment at the skilled nursing facility 
level is not appropriate in this case. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee has not progressed enough to be 
discharged from the facility. The Plan denied your request. The Plan says based on Medicare guidelines, the 
request for approval of continued admission in SNF does not meet the requirements for approval. 
 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 there are no identifiable skilled nursing service 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
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 enrollee is medically appropriate for 
LTACH admission. The Plan denied your request. The Plan says the denial of authorization for LTACH care 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 continues to receive acute care services that have not been denied. The 
record does not indicate that the enrollee requires services at the LTACH that are not currently being received. 
 
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.