Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0651, E0667) provided 
on April 25, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you disagree with the denial and 
have submitted supporting documentation. You are asking the plan to reprocess the claim. The Plan denied 
your request. The Plan says pneumatic compression devices are not covered by Medicare for type 2 diabetes 
mellitus with stage 1 chronic kidney disease and HTN, long term use of insulin, hypercholesteremia and Covid 
19. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
 The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device 
(E0651, E0667) provided on April 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77062 billed for date of service January 25, 
2022. 
 
You asked the Plan to pay for procedure code 77062. 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 77062 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 77062 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code 77062 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 77062 billed for date of service January 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two surgical placements of implant bodies: endosteal 
implants (D6010 x2) and radiographic/surgical implant index (D6190) provided on February 11, 2022. 
 
You asked the Plan to pay for the endosteal implants and radiographic/surgical implant index. You say that you 
thought implants were covered under the extended plan. The Plan denied your request. The Plan says these 
services are not covered benefits under your insurance plan. 
 
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 the two surgical placements of implant bodies: 
endosteal implants (D6010 x2) and radiographic/surgical implant index (D6190) provided on February 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for recement crown, tooth 3 provided on May 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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 requested service was exhausted on date of service May 3, 2022. Therefore, we 
decided that the Plan does not have to pay for recement crown, tooth 3 provided on May 24, 2022.
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 you are appealing for the denied authorization of 
inpatient rehabilitation admission. The Plan denied your request. The Plan says your current care needs do not 
meet Medicare criteria for admission to an inpatient rehabilitation facility. 
 
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 were admitted to an acute hospital on September 1, 2022 after a fall 
sustaining a non-displaced right tibial tuberosity fracture treated non-operatively with an immobilizer and non-
weight bearing on right lower extremity. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. While you have a need for physical or occupational therapy, there is no documented need 
for intensive rehabilitation services. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code 81455) provided on April 
4, 2022. 
 
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 date of service for a clinical laboratory test or the technical component of 
physician pathology service must be the date the specimen was collected. 
 
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 claim was billed 
with a date of service inconsistent with Medicare rules governing laboratory services. The specimen was 
collected on March 10, 2022, rather than the billed date of service April 4, 2022. Therefore, we decided that the 
Plan does not have to pay for the laboratory services (CPT code 81455) provided on April 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 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 the enrollee appears to be still unstable and requires only short-term additional acute 
care services that can safely be administered at the current facility until more stable for transfer to a lower level 
of care. There are no services at the LTACH that the enrollee requires that are not already available and 
covered at the current facility. Transfer to the LTACH is not medically necessary as the enrollee is not 
clinically stable for transfer at this time (Dobhoff tube), and it would not be clinically advantageous. 
Completion of treatment at the current facility is recommended. 
 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 21, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the claim was 
billed with the incorrect date of service. 
 
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 payment for CPT code 81479 is not supported in the medical record. Specifically, the lab services 
should be billed on the date the specimen was collected. The records show that the specimen was collected on 
June 4, 2021. This means that the claim was billed with the incorrect date of service. Based on this information, 
we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on June 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the full mouth debridement (D4355) provided on April 12, 2022. 
 
You asked the Plan to pay for the full mouth debridement. You say that you told the front desk that you only 
wanted a cleaning and x-rays prior to the services being rendered. The Plan denied your request. The Plan says 
this service is not a covered expense under your dental plan. The Plan also says that you did not contact the 
Plan prior to the date of service to verify benefits and provider eligibility. 
 
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 the full 
mouth debridement (D4355) provided on April 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pharmacogenomic testing provided on March 29, 2022. 
 
You asked the Plan to pay for the pharmacogenomic testing. You say that the claim should be paid. The Plan 
denied your request. The Plan says the service is not covered as billed. 
 
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 pharmacogenomic testing have not been met. The provider 
ordered a pharmacogenomic test panel. The laboratory billed multiple individual Current Procedural 
Terminology (CPT) codes with the same date of service. Procedures shall be reported with the most 
comprehensive CPT code that describes the services performed. Providers/suppliers must not unbundle the 
services described by a HCPCS/CPT code. If one laboratory procedure evaluates multiple genes using a next 
generation sequencing procedure, the laboratory shall report only one unit of service of one genomic 
sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code. Therefore, we decided that the Plan does not have to pay for the 
pharmacogenomic testing provided on March 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental implant removal and bone replacement graft for 
ridge preservation provided on May 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental services were medically necessary. 
The Plan denied your request. The Plan says the dental services were received from an out-of-network provider 
and are not covered by 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a dental implant removal and bone replacement graft for ridge preservation provided on 
May 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant supported crown, porcelain fused to high noble 
alloys for teeth # 19 and 30 (CPT code D6066). 
 
You asked the Plan to pre-approve the dental service. You say that the service is necessary. The Plan denied 
your request. The Plan says the service is not a covered benefit under 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, the requested items or services are not 
among those covered under this benefit. This service/dental code is not listed in your EOC as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pre-approve implant supported 
crown, porcelain fused to high noble alloys for teeth # 19 and 30 (CPT code D6066).
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 you are appealing the denial of inpatient 
rehabilitation admission. The Plan denied your request. The Plan says medical necessity for acute inpatient 
rehabilitation has not been met as the records do not show a need for an intensive program with a team of 
health care professionals and doctors that specialize in complex medical needs or an interdisciplinary team 
approach to the delivery of rehabilitation care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee was admitted to an acute hospital on August 24, 2022 with 
pneumonia, a urinary tract infection and treated with antibiotics. The enrollee was in acute on chronic 
respiratory failure, also treated and stabilized. The enrollee left with debility. There are no complex nursing or 
rehabilitation needs. While the enrollee has a need for physical or occupational therapy, there is no documented 
need for intensive rehabilitation services. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the occlusal orthotic device (CPT code D7880). 
 
You asked the Plan to pre-approve the device. You say that the ongoing treatment appliance has been cracked, 
repaired and cracked again due to day-to-day wear and tear and requires replacing. The Plan denied your 
request. The Plan says the services requested are purely dental in nature and they are unrelated to the limited 
clinical indications. The Plan states the services are not eligible for coverage under the medical benefit. 
 
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 device have not been met. Oral appliances generally are 
classified as dental devices and are not classified as durable medical equipment. The following items (not all-
inclusive) are considered to be dental devices and will be denied as non-covered, not DME: Oral occlusal 
appliances used to treat temporomandibular joint (TMJ) disorders. Therefore, we decided that the Plan does not 
have to pre-approve the occlusal orthotic device (CPT code D7880).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the endodontic therapy, of a premolar tooth 
(excluding final restoration) (D3320) provided on May 3, 2022. 
 
You asked the Plan to issue reimbursement for the dental service. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the dental service 
was received from an out-of-network provider and is not covered by 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. 
 
The record shows that you received the dental service from an out-of-network provider. Though the Plan offers 
a dental benefit in excess of Medicare coverage, the service provided is not covered under this benefit when 
received from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the endodontic therapy, of a premolar tooth (excluding final restoration) (D3320) provided 
on May 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the application of caries arresting medicamentper tooth 
(D1354 x 2) provided on April 11, 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 this service is not a covered benefit under 
your contractual policy. 
 
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 services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the application of 
caries arresting medicamentper tooth (D1354 x 2) provided on April 11, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from May 7, 2021, through 
June 25, 2021. 
 
You asked the Plan to pay for home health services. You say that you are requesting reconsideration as no 
payment has been received. The Plan denied your request. The Plan says the provider did not submit the RAP 
claim until June 24, 2021. 
 
The Plan must follow Medicare rules. Medicare rules say that HHAs must submit a RAP within 5 calendar 
days after the start of care date for initial 30-day periods and within 5 calendar days after the from date for 
each subsequent 30-day period of care. 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, the RAP was not submitted within 5 
calendar days. Therefore, we decided that the Plan does not have to pay for home health services provided from 
May 7, 2021, through June 25, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the services (99219) provided on September 30, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the procedure has 
been billed and allowed the maximum number of times allowed by our payment policy. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan argues that this service has reached the maximum allowable benefit. 
However, the Plan has not provided documentation showing that this service can only be billed and paid a 
maximum number of times. Without supporting documentation, the Plan's denial cannot be substantiated. 
Therefore, we decided that the Plan has to pay for the services (99219) provided on September 30, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99239) provided on March 29, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service is not 
supported. 
 
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 99239 is "Hospital discharge day management; more than 
30 minutes". 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the records do not show that 
more than 30 minutes of hospital discharge day management services were provided on the date of service in 
question. 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 (99239) provided on March 29, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for oxygen equipment provided on May 3, 2022, by an out-of-network (OON) provider.

You asked the Plan to pay for oxygen equipment. You say that you would like to request reconsideration of the denied claim. The Plan denied your request. The Plan says the DME services are denied because the service cannot be covered under your plan for non-contracted services, per the member evidence of coverage.

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 oxygen equipment provided on May 3, 2022, by an out-of-network (OON) provider.