Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry (83789) 
billed for date of service February 7, 2022. 
 
You asked the Plan to pay for mass spectrometry services. You say that this service is supported as billed. The 
Plan denied your request. The Plan says this service is not separately payable from the drug testing services 
provided. 
 
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 mass spectrometry 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 mass spectrometry and tandem mass spectrometry (83789) billed for date 
of service February 7, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a mental health telehealth visit on April 13, 
2022. 
 
You asked the Plan to waive the copayment for a mental health telehealth visit. You say that you are not aware 
of any office visit or phone visit with this provider, and you should not be responsible for this copayment. The 
Plan denied your request. The Plan says the copayment has been applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for each telehealth outpatient mental health or outpatient psychiatric individual therapy visit.  
 
You have been asked to pay $30 for a mental health telehealth visit. A mental health telehealth visit falls within 
the Outpatient Mental Health Care benefit category. Records submitted by the provider support this service was 
rendered. This means that you have been asked to pay the correct amount based on your contract with the Plan.  
 
 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 waive the copayment for a mental health telehealth visit on April 13, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the facet joint injections (CPT code(s): 64494, 64493, 
64495). 
 
You asked the Plan to pre-approve the facet joint injections. You say that the injections are necessary. The Plan 
denied your request. The Plan says your doctors note from September 9, 2022, does not mention any injection 
procedure to be done, the location on the spine to be injected, or why an injection is medically needed. 
 
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 facet joint injections. Our physician 
reviewer found you have radicular symptoms that correspond to foraminal stenosis noted on the magnetic 
resonance imaging (MRI). The requested procedure is does not meet the criteria and therefore, are considered 
not medically reasonable or necessary. 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 facet joint injections have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the facet joint injections (CPT 
code(s): 64494, 64493, 64495).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and mandibular 
partial denture (D5214). 
 
You asked the Plan to pre-approve the dentures. You say that you need the dentures so you can eat. The Plan 
denied your request. The Plan says these services are not covered under your benefit package. 
 
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 pre-approve a 
complete maxillary denture (D5110) and mandibular partial denture (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve expandable controller (E2377) electronic connection 
between wheelchair controller and two or more power seating system motors (E2311) and harness (E2313). 
 
You asked the Plan to pre-approve the upgraded electronics. You say that additional information is attached for 
the justification of the enrollee's wheelchair. The Plan denied your request. The Plan says the enhanced 
electronics E2377, E2311 and E2313 exceeds the enrollee's needs. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the upgraded electronics. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this case the enrollee has a neurologic disorder with functional deficits. The 
criteria for a power wheelchair are met. The requested electrical accessories are not medically necessary as the 
enrollee does have use of the upper extremity and can operate and control the power options using the switches 
that are included in the basic wheelchair. 
 
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 upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve expandable controller (E2377) electronic connection between wheelchair 
controller and two or more power seating system motors (E2311) and harness (E2313).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the patient has been waiting in the hospital for a 
week and needs to be discharged to rehab. The patient has no use of the left side and can't place any weight on 
her feet, leaving them at a risk of fall and injury. The Plan denied your request. The Plan says that IRF care is 
not medically necessary as the patient can be managed at a lower level of 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that patient has multiple hospital complications that  will continue to require close monitoring on an 
inpatient basis. Evaluating therapists document that the patient will tolerate intense therapy and multiple trauma 
is an IRF compliant diagnosis thus medically necessary 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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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 pre-approve provisional pontics on tooth #3, 6, 7, and 8 (D6253). 
 
You asked the Plan to pre-approve pontics. You say that you know this service is covered and it needs to be 
approved. The Plan denied your request. The Plan says provisional pontics (D6253) 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 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 pre-approve 
provisional pontics on tooth #3, 6, 7, and 8 (D6253).
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 22, 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 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation and endodontic therapy 
(D3310, D0150) 
 
You asked the Plan to pre-approve the comprehensive oral evaluation and endodontic therapy. You say that the 
services should be covered as you disagree with the denial. The Plan denied your request. The Plan says the 
services denied correctly as they do not fall within 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 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 pre-approve a 
comprehensive oral evaluation and endodontic therapy (D3310, D0150)
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tyvaso. 
 
You asked the Plan to pre-approve Tyvaso. You say that the requested drug is necessary for the enrollee's 
diagnosis. You also say that the enrollee would like a tier exception due to lack of generic availability. The 
Plan denied your request. The Plan says the requested drug is not approved by the FDA for the enrollee's 
diagnosis. The Plan says that a tier exception is only allowed for certain drugs covered under Medicare Part D. 
The Plan also says the requested drug is covered under Medicare Part B and therefore not eligible for a tier 
exception. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Tyvaso. Our reviewer says that the 
requested drug, Tyvaso, is not medically necessary. Our physician reviewer found the provided documentation indicates that the enrollee has a Trilogy ventilator for their obstructive sleep apnea (OSA). The reviewer found 
the documentation does not include compliance reports or overnight oximetry while using the Trilogy to show 
that hypoxemia has been adequately treated. Tyvaso is FDA-approved for Group I PH, and for group III due to 
interstitial lung disease. There are potential risks of worsening hypoxemia in patients with COPD, and use of 
Tyvaso in these patients has not been adequately studied. Therefore, the reviewer found that the requested drug 
is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tyvaso have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Tyvaso.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service September 
23, 2021. 
 
You asked the Plan to pay for procedure code 99053. You say that this service was medically necessary. The 
Plan denied your request. The Plan says procedure code 99053 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 99053 has a status indicator of B on the Physician Fee Schedule. This means that procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service September 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for one-way allow prorated trip in connection with medically 
necessary laboratory specimen collection drawn from home bound or nursing home bound provided on 
December 3, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for one-way allow prorated trip. You say that you are appealing the claim payment 
denial. The Plan denied your request. The Plan says the services were provided out-of-network and were not 
approved in advanced. 
 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 one-way allow prorated trip in connection with 
medically necessary laboratory specimen collection drawn from home bound or nursing home bound provided 
on December 3, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 You asked the Plan to pre-approve Prolia. You say that the requested drug will keep your diagnosis from 
getting worse. The Plan denied your request. The Plan says you have not tried and failed the preferred drug, 
bisphosphonate. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
that you have tried and failed the preferred drug. The reviewer found that there is no indication that the plan's 
required drug would likely be less effective and/or likely have adverse effects for you. Therefore, the reviewer 
found that the step therapy 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the acute inpatient hospital care 
provided from November 30, 2021, to December 6, 2021. 
 You asked the Plan to pay an additional amount for the inpatient care. You say that the billing of the secondary 
diagnosis code is supported. The Plan denied your request. The Plan says the billing of secondary diagnosis 
code J96.21, acute and chronic respiratory failure with hypoxia, is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code, J96.21, defined as, acute 
and chronic respiratory failure with hypoxia. We asked our physician reviewer to carefully review the case file 
and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay an 
additional amount for the inpatient care. Our reviewer says that the billing of the secondary diagnosis code is 
not supported. Our physician reviewer found although the provider documented acute and chronic respiratory 
failure with hypoxia, reasonable support within the health record must be present for that diagnosis. The review 
has determined that the provided documentation did not support the billing of secondary diagnosis code J96.21, 
acute and chronic respiratory failure with hypoxia.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
an additional amount for the acute inpatient hospital care provided from November 30, 2021, to December 6, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on November 15, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the services at issue in this appeal. 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 the services provided on November 15, 2021, by an out-of-
network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that based on the enrollee's medical condition Medicare 
guidelines have been met for IRF admission. The Plan denied your request. The Plan says that based on 
Medicare guidelines, the inpatient rehabilitation facility services you are requesting do not meet the 
requirements for approval. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found although degloving injury is not an IRF compliant diagnosis, clinical documentation shows that the 
enrollee requires close medical monitoring of lower limb compartment pressure on an inpatient basis. 
Evaluating physical and occupational therapists recommend intense therapy and that the enrollee can tolerate 
three hours of therapy per day.  The IRF criteria has been met and is medically necessary. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute IRF admission and services.  
 
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the bilateral physiologic studies provided on February 15, 2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says that the 
diagnosis billed was not appropriate. 
 
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. 
 
We looked at the file and the rules. The Local Coverage Article, A57126, is not binding in this case. The rule 
does not have Medicare Part B jurisdiction where the services were provided. No other valid denial rationale 
was presented by the Plan. The Plan has not made reasonable and diligent efforts to gather and forward to us 
information regarding their decision to deny your request.  Therefore, we decided that the Plan has to pay for 
the bilateral physiologic studies provided on February 15, 2022.  
 
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.