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

 
We decided that the Plan does not have to pay for the lidocaine injection (J2001) and the bupivicaine 
hydrochloride injection (S0020) provided on July 29, 2021. 
 
You asked the Plan to pay for codes J2001 and S0020. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
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 J2001 
is a column II code to column I code 64447. This claim has not been billed with an appropriate modifier to 
bypass the edit. We also find that CPT code S0020 has a Status Indicator of I on the Physician Fee Schedule. 
This means that CPT code S0020 is not valid for Medicare purposes. Based on the claim submitted, Medicare 
billing criteria have not been met. 
 
Therefore, we decided that the Plan does not have to pay for the lidocaine injection (J2001) and the bupivicaine 
hydrochloride injection (S0020) provided on July 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two surgical extractions (D7210 x2), two surgical 
placements of implant bodies: endosteal implants (D6010 x2), bone graft at time of implant placement 
(D6104), consultation (D9310), and two drugs or medicaments dispensed in the office for home use (D9630 
x2) provided from August 3, 2021, to November 15, 2021. 
 
You asked the Plan to pay for the surgical extractions, endosteal implants, bone graft, consultation, and drugs 
or medicaments. You say that you would like to be reimbursed for these services. The Plan denied your 
request. The Plan says these services are not covered expenses under your dental 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. Therefore, we decided that the Plan does not have to pay for the two 
surgical extractions (D7210 x2), two surgical placements of implant bodies: endosteal implants (D6010 x2), 
bone graft at time of implant placement (D6104), consultation (D9310), and two drugs or medicaments 
dispensed in the office for home use (D9630 x2) provided from August 3, 2021, to November 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the gradient compression stockings (CPT code 
A6531NU). 
 
You asked the Plan to pre-approve the gradient compression stockings. You say that the enrollee has persistent 
edema despite venous medical interventions the enrollee may also have lymphatic component. You state the 
enrollee has failed to respond to the lower strength 20-30mmgh compression stockings. The Plan denied your 
request. The Plan says the enrollee does not have open venous stasis ulcers that have been surgically treated, 
modified or debrided. 
 
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 gradient compression stockings. Our physician reviewer found the documentation does not support that the enrollee has any open wounds 
caused by or treated by a surgical procedure. The requested gradient compression stockings are 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 the gradient compression stockings have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the gradient compression stockings (CPT code A6531NU).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Arnasep (CPT code J0881). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the provider did not address our step therapy requirement. The Plan states their 
current information does not indicate the enrollee has tried and failed our preferred step therapy drugs- for at 
least two (2) consecutive months, with appropriate dose adjustment. The Plan states there is no indication the step therapy drugs would likely be: less effective, and/or cause adverse effects for the enrollee. The Plan states 
they approved Procrit under the enrollee's Part B plan for 180-day. 
 
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 the medication. Our physician reviewer 
found there is no indication that the enrollee has tried and failed the required drug(s). There is no indication 
that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Arnasep (CPT code J0881).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation (D9310) provided on January 21, 2022. 
 
You asked the Plan to pay for the dental service. You say that your dentist referred to this provider. The Plan 
denied your request. The Plan says the consultation is not listed as a covered service. 
 
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 consultation is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the consultation 
(D9310) provided on January 21, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF is not 
medically necessary. 
 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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found based on the medical records 
provided there is no documentation that you require the services on an inpatient basis, only in a skilled nursing 
facility 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 the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from April 25, 2021, to April 
27, 2021. 
 
You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan says 
that the inpatient admission was not medically necessary. The Plan also says that an observational level of care 
would have been more appropriate. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee presented on April 23, 2021 as the percutaneous endoscopic gastrostomy 
(PEG) tube had fallen out. The patient was seeking re-insertion. Our reviewer found that the PEG was re-
inserted via upper endoscopy. Feeding was started. Once feeding was tolerated, the patient was discharged 
home. Our physician reviewer also found that the record showed that at the time of inpatient admission the 
admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency 
department and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the acute inpatient hospital care have been met. Therefore, we decided that the 
Plan has to pay for the acute inpatient hospital care provided from April 25, 2021, to April 27, 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hot or cold packs therapy (97010) provided on November 30, 2021. 
 
You asked the Plan to pay for hot or cold packs therapy. You say that these services have prior authorization 
and should be paid. The Plan denied your request. The Plan says they have agreed to cover the physical therapy 
services, however the payment for hot or cold packs therapy (97010) is always bundled into payment for 
another service and is 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 CPT code. 
 
We find that CPT code 97010 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 97010 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of hot or cold packs therapy have not been met. Therefore, we decided that the Plan does not have to pay for 
hot or cold packs therapy (97010) provided on November 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81479 and 81404) provided on 
September 22, 2021. 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services (81479 and 81404) provided on September 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110), partial lower denture 
(D5214), and crowns (D2740 x 2). 
 
You asked the Plan to pre-approve the dentures. You say that you need these services. The Plan denied your 
request. The Plan says dentures are not covered services. 
 
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 complete upper denture 
and partial lower denture are not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to pre-approve a complete upper denture (D5110), partial lower denture (D5214), and crowns 
(D2740 x 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the root canal (D3320) provided on January 14, 2022 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay more for the root canal. You say that this root canal was provided on an emergency 
basis. You also say that you would like the Plan to reconsider the payment. The Plan denied your request. The 
Plan says this service was performed by a non-participating provider. You are responsible for any difference 
between the Maximum Allowable Fee and the amount the provider bills you for the services. 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, you are responsible for a 75% 
coinsurance, plus the difference between the billed amount and allowed amount because the service was 
received OON. Therefore, we decided that the Plan does not have to pay more for the root canal (D3320) 
provided on January 14, 2022 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).

You asked the Plan to pre-approve the CGM. You say that you need to get your blood sugar under control to lose weight in order to have a surgery. You need to test twice a day and do not like pricking your fingers. The Plan denied your request. The Plan says you do not meet the criteria for a CGM.

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 you do not use insulin with at least three daily administrations. 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 continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the four two dimensional (2D) oral/facial photographic 
images (D0350 x4) provided on February 8, 2022. 
 
You asked the Plan to pay for the 2D oral/facial photographic images. You say that it was necessary for you to 
have these x-rays taken, due to the extensive dental procedure you need done. The Plan denied your request. 
The Plan says this service is not a covered expense under your dental 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 four 
two dimensional (2D) oral/facial photographic images (D0350 x4) provided on February 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system with electronic 
connection, expandable controller with harness, accessories transit kit, a positioning/safety belt, and calf panel. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a power seat elevation feature (E2300) and power 
standing feature (E2301) are non-covered because they are not primarily medical in nature. Medicare rules say 
that an electronic connection is used to control multiple power options. The rules say that code replacement 
calf pads are described by code E0995. The rules say that each power wheelchair code is required to include a 
lap/safety belt items on initial issue. The rules state that for equipment to be covered, it must be appropriate and 
needed for use inside the home. 
 
We looked at the file and Medicare rules. The requested power seat elevation feature with electronic 
connection is not covered by Medicare. The file shows that the electronic connection is not needed to control 
the approved power switches. The calf pads were requested under code K0108. This code is not appropriate for 
these services, as it should be requested under code E0995. The requested E0978 seat belt is not covered 
because it is already covered in the approved wheelchair. The requested transit option is for use outside of the 
home and cannot be approved. 
 
Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system with electronic 
connection, expandable controller with harness, accessories transit kit, a positioning/safety belt, and calf panel.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction (D7210) provided on May 26, 2021. 
 
You asked the Plan to pay for the dental service. You say that you did not know that you needed an 
authorization. The Plan denied your request. The Plan says 1 extraction is covered per year. The Plan says that 
the frequency limit has been exceeded. The Plan also says that you signed a treatment plan acknowledging you 
would be financially responsible for the out of pocket expense for the additional tooth extraction. 
 
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 and 1 extraction is covered per year, the 
frequency limit has been exceeded. Additionally, the record shows that you signed a treatment plan 
acknowledging you would be financially responsible for the out of pocket expense for the additional tooth 
extraction. Therefore, we decided that the Plan does not have to pay for the extraction (D7210) provided on 
May 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immediate maxillary denture (D5130), three simple 
extractions (D7140 x3), and surgical extraction (D7210) provided on January 20, 2022. 
 
You asked the Plan to pay for the immediate maxillary denture and extractions. You say that the doctor 
recommended you get a partial immediately so you could chew hard food better. You also say that you feel you 
should be compensated for these services. The Plan denied your request. The Plan says the immediate 
maxillary denture is not a covered expense under your dental plan. The Plan also says that your extractions 
benefit has been satisfied and the frequency limitation has been exceeded. 
 
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, immediate maxillary denture (D5130) 
is not among those covered under this benefit. The contract says that extractions are limited to 2 procedure 
codes per calendar year. The record shows that you received five simple extractions (D7140 x5) on January 20, 
2022, two of which were covered by the Plan, and your extractions benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pay for the immediate maxillary denture (D5130), three simple 
extractions (D7140 x3), and surgical extraction (D7210) provided on January 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 3 additional acupuncture visits. 
 
You asked the Plan to pay for the acupuncture visits. You say that you received a denial of the acupuncture 
which you really need. You feel a lot better receiving acupuncture services and you want to continue with the 
services. The Plan denied your request. The Plan says the records do not support that the 3 additional visits is 
medically necessary. 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plan's rules apply in this case. 
 
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 acupuncture visits. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the reviewed documentation indicates that based on peer-to-peer discussion, 
practitioner indicated that both enrollee and she will be on vacation, that was the reason for a longer treatment 
period. She already talked with the enrollee about this modification of service, and it works perfectly for both. 
If more visits are needed, practitioner will submit a new MNR for review. Therefore, she agreed to keep the 
prior approval with no additional visits. The request for 3 additional visits is not needed at this time. 
 
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 acupuncture visits have not been met. Therefore, we decided that the Plan 
does not have to pay for 3 additional acupuncture visits.