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

 
We decided that the Plan does not have to pre-approve crowns (D2751) for tooth #'s 26 and 27. 
 
You asked the Plan to pre-approve the crowns. You say that you have 2 holes in the tooth, and need to have the 
crown on it since a filling will be worthless on your tooth. You also say that you do not have money to pay for 
these services. The Plan denied your request. The Plan says the submitted x-ray does not show proof of a 
completed root canal fill to within 2.0 mm of the end of the root(s). The Plan also says root canal re-treatment 
typically results in damage to a crown necessitating re-doing the crown. 
 
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 crowns 
when the services are medically necessary and reasonable.  
 
 
  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 crowns. Our reviewer says that the 
documentation provided does not meet the criteria for coverage for crown restorations for tooth #'s 26 and 27. 
Our physician reviewer found the documentation indicates that root canal treatment for tooth #'s 26 and 27 has 
been approved. However, the documentation of the completed root canals was not included in the 
documentation. Our reviewer also found that completed root canals filled within 2 millimeters of the apex must 
be documented according to the criteria for coverage for crown restorations. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crowns have not been met. Therefore, we decided that the Plan does not 
have to pre-approve crowns (D2751) for tooth #'s 26 and 27.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 14, 2022, to 
June 12, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from May 14, 2022, to June 
12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes B4197, B4220, and B4224 billed for date of 
service August 20, 2021. 
 
You asked the Plan to pay for procedure codes B4197, B4220, and B4224. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT codes B4197, B4220, and B4224 is 1. The MAI value for this code is 3. You 
billed 7 units of each of these codes, exceeding the MUE. You did not provide all the required evidence 
showing that the excess units were actually provided, were correctly coded, and were medically necessary. 
Based on this information, we decided that Medicare rules for coverage of procedure code B4197, B4220, and 
B4224 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
B4197, B4220, and B4224 billed for date of service August 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve ablation. 
 
You asked the Plan to pre-approve genicular nerve ablation. The Plan denied your request. The Plan says this is 
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 genicular nerve ablation. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that this is considered an experimental procedure which is the subject of ongoing 
clinical trials. Therefore, the request is deemed not medically reasonable and 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 genicular nerve ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve ablation.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 4, 2022, to July 
3, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from June 4, 2022, to July 3, 
2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. The Plan denied your request. The Plan says the records do not 
show the enrollee needs daily rehabilitation 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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on June 27, 2022. 
 
You asked the Plan to pay for the physician's services. You say that you have a PPO Plan and you were told 
that you could see an out-of-network provider, so you sent in your claim for reimbursement it was denied. You 
say that you were never told that you could not see this doctor. The Plan denied your request. The Plan says the 
servicing provider has elected not to participate in Medicare. The Plan cannot allow payment for any Medicare 
claims to this provider. 
 
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 
physician's services provided on June 27, 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. The Plan denied your request. The Plan says the 
enrollee does not have clinical conditions that cannot be appropriately treated in the current hospital, and there 
are no issues for which LTACH may offer a therapeutic advantage. 
 
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 continued care in the short-term acute hospital is appropriate until the enrollee is 
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. 
 
 
 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: Favorable

 
We decided that the Plan has to pay for a new patient office visit, 30-44 minutes (code 99203) provided on 
August 3, 2022. 
 
You asked the Plan to pay for the new patient office visit. You say that there are no other providers that had a 
new patient appointment with this member. The Plan denied your request. The Plan says that the patient's 
claims history indicates they have received face-to-face services by another provider of the same specialty who 
belongs to the same group practice within the past three years. 
 
The Plan must follow Medicare rules. Medicare rules say that the phrase "new patient" means a patient who has 
not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) 
from the physician or physician group practice (same physician specialty) within the previous 3 years. 
 
We looked at the file and Medicare rules. The file shows that the services, referenced by the Plan, provided on 
July 9, 2022 were for initial hospital inpatient care services (code 99221), not for a new patient office visit,  
30-44 minutes (code 99203) and the rendering provider is not of the same specialty as the provider at issue in 
this case. Based on this information, we decided that Medicare rules for coverage of the new patient office visit 
have been met. Therefore, we decided that the Plan has to pay for a new patient office visit, 30-44 minutes 
(code 99203) provided on August 3, 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from July 31, 2020 to 
August 4, 2020, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
diagnosis of Sepsis is supported based on the Sepsis 2 criteria. The Plan denied your request. The Plan says the 
medical record received and available for review does not support the condition treated as consistent with a 
systemic infectious process. 
 
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 principal diagnosis code, A41.9, defined as Sepsis, 
unspecified organism. 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 for the inpatient hospital 
services at the DRG originally billed. Our reviewer says that the submitted DRG is not supported. Our 
physician reviewer found there was no clinical or laboratory evidence of sepsis. The enrollee was 
hemodynamically stable throughout the hospitalization. Our reviewer also found that the documentation did not 
support diagnosis code A41.9.  
 
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 
for the inpatient hospital services provided from July 31, 2020 to August 4, 2020, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72131 billed for date of service May 27, 
2022. 
 
You asked the Plan to pay for procedure code 72131. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 72131 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 72131 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 72131 billed for date of service May 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is medically stable to be 
transferred to an LTACH as this is the appropriate level of care. The Plan denied your request. The Plan says 
an LTACH admission is not medically necessary, and the enrollee can safely receive the services they need in 
the current hospital setting. 
 
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 that there is no documentation that was provided indicating medical necessity for 
admission to a LTACH. The enrollee does not require services at the LTACH that are not available at the acute 
care hospital where the enrollee is currently receiving care. 
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management services provided on 
April 29, 2022. 
 
You asked the Plan to pay for the hospital discharge day management services. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the enrollee was enrolled in hospice for this date 
of service.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the hospital discharge day management services provided on 
April 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99153 billed for date of service July 14, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the rules for 
payment have not been met. 
 
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 CPT code 99153 is a technical component only code. The total relative value units for technical 
component only codes under the physician fee schedule include values for practice expense and malpractice 
expense only. Based on this information, we decided that Medicare rules for coverage of the billed services 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99153 billed 
for date of service July 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the enrollee is having difficulty with the traditional 
glucose meter. The Plan denied your request. The Plan says the Medicare criteria for a CGM was not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
  We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic 
continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the testing (0013M) provided on July 26, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says that payment was 
recouped. 
 
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 records show that the Plan made payment for the requested services, but 
then denied the services and recouped payment. The Plan has not provided a denial rationale. Without a denial 
rationale, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the 
testing (0013M) provided on July 26, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 8360, 88361, and 88341 billed for date of 
service January 7, 2022. 
 
You asked the Plan to pay for procedure code(s) 8360, 88361, and 88341. The Plan denied your request. The 
Plan says these codes are included in the facility payment and are not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 8360, 88361, and 
88341. This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 8360, 88361, 
and 88341. Based on this information, we decided that Medicare rules for coverage of procedure code 8360, 
88361, and 88341 have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
code(s) 8360, 88361, and 88341 billed for date of service January 7, 2022.