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

 
We decided that the Plan does not have to pay more for the dental services on March 29, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you feel that you should not owe anything. 
The Plan denied your request. The Plan says you are responsible for any charged amount above the Plans cost-
sharing amount when your services are received from an out-of-network provider. 
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for the dental services on March 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to provide coverage for a power wheelchair and accessories for the enrollee.
You asked the Plan to provide coverage for a power wheelchair for the enrollee. You say that the power wheelchair and accessories are medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare does not cover durable medical equipment for residents of a SNF. Maximus overturned the Plans denial for medical necessity. The Plan requested a reopen and stated that Maximus did not apply the correct criteria. The issue was not the need for the equipment but the fact that the enrollee is a SNF resident which prevents coverage for this equipment by Medicare.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. The records show that this equipment is being requested for use in a SNF. Therefore, we decided that the Plan does not have to provide coverage for a power wheelchair and accessories for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy (PT) services provided from January 23, 
2021, to February 2, 2021. 
 
You asked the Plan to pay for the PT services provided from January 23, 2021, to February 2, 2021. You say 
that the claims should be reprocessed for payment. The Plan denied your request. The Plan says the claims 
were denied correctly. 
 
The Plan follows Medicare rules. The rules say that a party may request a contractor reopen and revise its 
initial determination or redetermination within 1 year from the date of the initial determination or 
redetermination for any reason.  
The record shows that corrected claims for the PT services provided from January 23, 2021, to February 2, 
2021, were not filed until February 11, 2021. This means that more than one calendar year from the initial 
determinations had passed before corrected claims were filed. Therefore, we decided that the Plan does not 
have to pay for the physical therapy (PT) services provided from January 23, 2021, to February 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound therapy services (97035 x 3) provided from 
April 7, 2022, through April 16, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit under 
your contractual policy or by Medicare. 
 
 
 
 
 
 
 
  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the ultrasound therapy services (97035 x 3) provided from April 7, 2022, 
through April 16, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you need therapy immediately and you are currently 
at risk of falling at the facility you are in. The Plan denied your request. The Plan says the records do not show 
that the enrollee needs daily skilled rehabilitation services. The services the enrollee requires can safely be 
received at a different setting like home with home health or in residential care with part-time therapy services. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have documented skilled nursing needs. The enrollee does 
not have documented skilled therapy needs. The enrollee is ambulating more than 100 feet. Daily skilled 
services are not shown to be required to establish a maintenance program or to prevent deterioration of the 
enrollees condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusal guard (D9944) received on June 14, 2022. 
 
You asked the Plan to pay for an occlusal guard. You say that you want the Plan to pay for the service. The 
Plan denied your request. The Plan says the service at issue is not a covered 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 an 
occlusal guard (D9944) received on June 14, 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 you have been in a hospital because you had surgery, 
and need physical therapy to strengthen your muscles and help you get around better. The Plan denied your 
request. The Plan says you do not meet the conditions for a stay in an IRF. 
 
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 you do not need intensive therapies consisting of at least 3 hours of therapy per day at 
least 5 days per week with multidisciplinary approach in an IRF. Our reviewer also found that while you may 
benefit from continued physical therapy and occupational therapy, your rehabilitation needs can be safely 
provided in a lower intensity and alternate setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Favorable

 
We decided that the Plan has to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are medically 
necessary. The Plan denied your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient admission are met in this case. Our 
physician reviewer found the review indicates that the record showed that at the time of inpatient admission the 
admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier 
emergency department and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pre-approve acute inpatient hospital care.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an insertion, subcutaneous cardiac rhythm monitor, 
including programming (33285). 
 
You asked the Plan to pre-approve implantable cardiac loop recorder (ILR). You say that the enrollee has an 
irregular heartbeat, diabetes and high blood pressure. The Plan denied your request. The Plan says a device 
inserted under the skin to monitor heart rhythm (ILR) does not meet the requirements for approval. 
 
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 implantable cardiac loop recorder 
(ILR). Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found while the enrollee has a history of atrial fibrillation, there 
is no documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or any other 
apparent indication for an ILR. In summary, there is insufficient documentation to support the medical 
necessity for insertion of an ILR in the enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implantable cardiac loop recorder (ILR) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an insertion, subcutaneous cardiac rhythm monitor, 
including programming (33285).
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 stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. 
 
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 are no services at the LTACH that the enrollee requires that are not already 
available and covered 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 LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (83789-59) provided on February 9, 
2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says no separate payment can be made for these 
services based on Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 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, we find that the testing described by the 
billed code is considered specimen validity testing which is not separately payable. Therefore, we decided that 
the Plan does not have to pay for the laboratory services (83789-59) provided on February 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat lumbar radiofrequency ablation (RFA) (64635, 
64636). 
 
You asked the Plan to pre-approve repeat RFA. You say that the enrollee previously had 100% pain relief 
following an injection in 2019. The Plan denied your request. The Plan says the medical necessity criteria have 
not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Facet Joint Interventions are considered medically 
reasonable and necessary for the diagnosis and treatment of chronic pain in patients if there is no non-facet 
pathology per clinical assessment or radiology studies that could explain the source of the patient's pain, 
including but not limited to fracture, tumor, infection, or significant deformity. 
 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 repeat RFA. Our reviewer says that the 
requested repeat RFA is not medically necessary. Our physician reviewer found the provided documentation 
does not include imaging to support the criteria establishing medical necessity for the RFA. Therefore, the 
reviewer found that the criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of repeat RFA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve repeat lumbar radiofrequency ablation (RFA) (64635, 64636).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 3, 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 are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, we find that the testing described by the billed code 
is considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on January 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the foot orthotics received on January 27, 2022. 
 
You asked the Plan to pay for foot orthotics. You say that a previous claim from the same provider was paid. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for the foot orthotics received on January 
27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services coded 81015 provided on January 19, 
2021. 
 
You asked the Plan to pay for the medical services coded 81015. You say that you would like this claim 
reprocessed based on the medical records. The Plan denied your request. The Plan says there are no modifiers 
allowed with this code pairing for separate payment to be made. 
 
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 81015 
is a column II code to column I code 81000 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 the medical services coded 81015 provided on January 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cytopathology, in situ hybridization (e.g., FISH), urinary 
tract specimen with morphometric analysis, 3-5 molecular probes (88120) provided on November 2, 2021. 
 
You asked the Plan to pay for genetic testing. You say that you do not agree with the denial and have submitted 
medical records. The Plan denied your request. The Plan says the services are not authorized because code 
88120 is not a Medicare benefit for the diagnosis of R31.9 and diagnosis R31.9, that you have listed on the 
claim, is done for screening purposes 
 
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 88120 is cystoscopy in conjunction with bladder tumor 
markers is standard practice to evaluate patients with symptoms suggesting bladder cancer and to monitor 
treated patients for recurrence or progression. Bladder cancer tumor markers performed by any technology 
immunoassay, molecular or FISH testing, are not covered for screening of all patients with hematuria. 
Bladder tumor markers are not expected to be performed until other diagnostic studies fail to identify the 
etiology of the hematuria. Moreover, Urine cytology is not considered a bladder tumor marker. 
 
We find that CPT code 88120 is not supported in the medical record. Specifically, code 88120 is not a 
Medicare benefit for the diagnosis listed. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for a 
cytopathology, in situ hybridization (e.g., FISH), urinary tract specimen with morphometric analysis, 3-5 
molecular probes (88120) provided on November 2, 2021.
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 you appear to still be critically ill and do not appear to be stable to transfer to an 
LTACH; you are still on vasopressors with tachycardia, leukocytosis and with a chest tube in place. Continued 
care in the short-term acute care hospital is appropriate until you are stable to transfer to a lower level of care 
such as an inpatient rehabilitation facility, a sub-acute rehabilitation facility or a skilled nursing facility or until 
your condition stabilizes and meets criteria for transfer to an LTACH. 
 
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 92929 billed for date of service January 28, 
2022. 
 
You asked the Plan to pay for procedure code 92929. You say that the medical records should be reviewed and 
the claim reconsidered for payment. The Plan denied your request. The Plan says procedure code 92929 is 
considered bundled and 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 procedure code. 
 
We find that procedure code 92929 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 92929 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 92929 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 92929 billed for date of service January 28, 2022.