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

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and 
tongue biopsy (41105) provided on April 4, 2022, by a Medicare opt out provider. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and tongue biopsy. You say that you 
were not aware that the Plan required pre-approval for this type of medical procedure, and it was not indicated 
that it was required. You also say that you assumed the biopsy was a medically approved method of detecting 
cancer. The Plan denied your request. The Plan says you received these services from a provider who chose not 
to receive Medicare funds. The Plan also says that this treating provider opted out of Medicare effective 
January 1, 2022, to January 1, 2024. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
problem focused limited oral evaluation (D0140) and tongue biopsy (41105) provided on April 4, 2022, by a 
Medicare opt out provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on February 15, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 The Plan must follow Medicare rules. Medicare rules say that to report a Molecular Diagnostic Test service, the 
appropriate claim information must be submitted.  
 
We looked at the file and Medicare rules. The claim in this case was not billed with an appropriate DEX Z-
Code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the testing provided on February 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on May 19, 2022. 
 
You asked the Plan to pay for physical therapy services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physical therapy services provided on May 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided March 22, 2022. 
 
You asked the Plan to pay for the orthosis. You say that please see all documentation that qualifies per MCR 
guidelines and the Plan LCD to process the claim for payment. The Plan denied your request. The Plan says the 
information submitted was insufficient for the code billed on the date of service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.   
The record does not contain valid relevant medical records which support medical necessity for the supplies 
provided in this case. Specifically, although there was an order and proof of delivery submitted, there is no 
face-to-face encounter, evaluation and management notes or progress notes to support the items. The record 
shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, 
we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided March 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service February 26, 
2022, to March 25, 2022. 
 
You asked the Plan to pay for procedure code S9328. 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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service February 26, 2022, to March 25, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Ustekinumab, for subcutaneous injection, 1 mg 90 
(J3357) provided on January 28, 2022. 
 
You asked the Plan to pay for this medication. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this medication is not covered under the 
enrollees contractual policy or by Medicare. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug provided is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the Ustekinumab, for 
subcutaneous injection, 1 mg 90 (J3357) provided on January 28, 2022.  
 
Additionally, please note that after looking at all of the information in this case, we found that the enrollee does 
not owe any money for this medication.  
 
Benefits for this medication 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: 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. The Plan denied your request. The Plan says you do not meet the 
Medicare criteria for admission to 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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. Our reviewer also found that 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on June 22, 2022. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that this exam should have 
been covered in full based on your benefit information. 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 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 
problem focused limited oral evaluation (D0140) provided on June 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a health club membership with personal trainer services 
provided from March 7, 2022, to April 14, 2022. 
 
You asked the Plan to pay for the health club membership with personal trainer services. You say that the 
personal trainer services are medically necessary to stretch your muscles and develop core and muscle strength. 
The Plan denied your request. The Plan says the non-contracted provider is not a recommended gym covered 
by the Plans fitness benefit program. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only when provided by the Plans fitness benefit program. 
 
The Plans rules for coverage of gym benefits have not been met because the health club is not a contracted 
Plan fitness benefit program provider. Therefore, we decided that the Plan does not have to pay for a health 
club membership with personal trainer services provided from March 7, 2022, to April 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation services (D0150) 
provided on April 22, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation services. You say that you had to go to a new 
dentist who charged you for these services. The Plan denied your request. The Plan says each time you see a 
new dentist they may bill for comprehensive oral evaluation services, but the Plan will only pay for this service 
once every three years. 
 
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 Plan covers the 
comprehensive oral evaluation services once every three years.  
 
We looked at the file and Medicare rules. In this case, the Plan provided confirmation that they had previously 
paid for comprehensive oral evaluation services on April 13, 2022. Therefore, the benefit limit for 
comprehensive oral evaluation services had been exhausted. Based on this information, we decided that the 
Plan's rules for coverage of the comprehensive oral evaluation services have not been met. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation services (D0150) provided on 
April 22, 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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says you do not meet criteria for IRF admission. 
 
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 you do 
not meet criteria for IRF admission. Our physician reviewer found the complexity of your nursing, medical and 
rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You were admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs.  
 
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
in an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different 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 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's condition has stabilized 
and he is ready for transfer to an LTACH. You say that the enrollee needs to be transferred to a LTACH 
instead of remaining in the current facility or discharging to a lower level of care, as he will require another 4-6 
weeks in acute care for transitioning from acute illness. The Plan denied your request. The Plan says the 
enrollee is receiving appropriate in-patient acute care and does not require transfer to an LTACH. 
 
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 more stable and improving and should only require short-
term additional acute care services that can safely be administered at the current facility until appropriate for a 
lower level of care. The enrollee does not require services at the LTACH that are not already available at the 
current facility. Transfer to the LTACH is not medically necessary as it would not be clinically advantageous at 
this time. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections (64493, 64494, 64495). 
 
You asked the Plan to pre-approve facet joint injections. You say that this service should be covered. The Plan 
denied your request. The Plan says the requested injections are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve facet joint injections. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation indicates a primary history of neurogenic claudication. The 
enrollee's symptoms and radiologic findings are more consistent with radicular pathology. His 6/2/22 medical 
progress note describes symptoms are numbing, tingling, sensory changes. The symptoms are increased with 
ambulation. Reflexes are depressed on exam. The clinical and imaging findings do not support that the 
enrollee's main symptoms are due to facet joint syndrome. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections (64493, 64494, 64495).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81479) provided March 22, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation provided does not support the billed service. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, 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. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of genetic testing (81479) provided 
March 22, 2022. have been met. Provided records were limited to lab results. No clinical documentation was provided to support the need for this service. Therefore, we decided that the Plan does not have to pay for 
genetic testing (81479) provided March 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair and attachments for the 
enrollee. 
 
You asked the Plan to pre-approve these services. You say that the enrollee needs a new wheelchair. The Plan 
denied your request. The Plan says that replacement due to wear is not covered during the reasonable useful 
lifetime of the equipment. 
 
The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of equipment in no 
case can be less than five years. The enrollee received a power wheelchair on August 13, 2019, which is less 
than five years ago. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power 
wheelchair and attachments for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional periapical x-ray (D0230) provided on April 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told by the dental hygienist that the x-
rays would be covered. 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 Plan's 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 periapical x-rays was exhausted on date of service April 18, 2022. Therefore, we 
decided that the Plan does not have to pay for an additional periapical x-ray (D0230) provided on April 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on January 26, 2022. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you feel you should 
not be held responsible for this charge because you were given incorrect information. The Plan denied your 
request. The Plan says your benefit for the requested item or service has already been exhausted. The Plan also 
say that no misinformation was provided to you regarding your dental benefits during your call with the Plan 
on January 5, 2022. 
 
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 item or service was exhausted on date of service January 11, 2022. 
Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation 
(D0140) provided on January 26, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service January 4, 
2022. 
 
You asked the Plan to pay for procedure code 70544. The Plan denied your request. The Plan says payment for 
code 70544 is bundled into payment for code 70551.  
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 70544 
is a column II code to column I code 70551. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 70544 billed for date of service January 4, 2022.