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

 
We decided that the Plan does not have to pay for the radiotracer injection provided on October 26, 2021, billed 
with code 38792-59-LT. 
 
You asked the Plan to pay for the injection as billed. You say that this is billed correctly and should be paid. 
The Plan denied your request. The Plan says all codes were approved except for 38792 as it is not separately 
paid from 38900. The modifier -59 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we have confirmed that code 38792 is a column II code to column I code 38900; however, 38792 
was billed with a modifier.  
 
We asked our coder 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 injection as billed. Our reviewer says that the 
documentation does not support separate payment for code 38792. Our reviewer found CPT 38792 would be 
inclusive to CPT 38900, as it would be inappropriate to report both identification codes of the same sentinel 
node. The operative report does not specify procedures performed for the 3 sentinel nodes. Therefore, the use 
of modifier -59 cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injection as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the radiotracer injection provided on October 26, 2021, billed with code 38792-59-LT.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete upper denture (D5110) and complete lower 
denture (D5120) provided on October 5, 2021. 
 
You asked the Plan to pay for the dentures. You say that you were advised by a plan representative that 
dentures would be covered. You say that you paid out of pocket for your first set. You also say that you feel 
these should be covered. The Plan denied your request. The Plan says that your annual maximum benefit has 
been reached. 
 
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 and dentures are listed as covered, the 
annual maximum benefit of $1,000 has been exhausted. The record shows that the Plan paid $54 for services received on February 15, 2021, $555 for the complete upper denture provided on October 5, 2021, and $391 for the complete lower denture provided on October 5, 2021. $54 + $555 + $391 = $1,000. Therefore, we decided that the Plan does not have to pay for the complete upper denture (D5110) and complete lower denture (D5120) provided on October 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant 
(D6010) provided on February 18, 2022. 
 
You asked the Plan to pay for the endosteal implant. You say that you were not told that implants were not 
covered. The Plan denied your request. The Plan says this service is not covered. 
 
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 
surgical placement of implant body: endosteal implant (D6010) provided on February 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from May 27, 2022, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from May 27, 2022, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary.  
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from May 27, 
2022, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental health 
treatment beyond the date in question of May 27, 2022, forward. Our physician reviewer found the enrollee did 
not require inpatient mental health treatment beyond May 27, 2022, as she was not a danger to herself or others 
and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was 
taking place beyond the date in question. It did not appear that the services for the dates in question were 
reasonably expected or medically necessary to improve the enrollees condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from May 27, 2022, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from May 27, 2022, 
forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the root canal therapy (D3330) provided on November 23, 2021. 
 
You asked the Plan to pay for the root canal therapy. You say that you would like to be reimbursed 50% of 
what you paid for the emergency root canal. The Plan denied your request. The Plan says your plan does not 
cover this procedure. 
 
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 root 
canal therapy (D3330) provided on November 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant supported porcelain/ceramic crowns (D6065) 
and an abutment supported cast metal crown (predominantly base metal) (D6063) for tooth 31. 
 
You asked the Plan to pre-approve implant supported porcelain/ceramic crowns and an abutment supported 
cast metal crown. You say that you need these services. The Plan denied your request. The Plan says these 
services are not covered under your benefits. 
 
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 pre-approve 
implant supported porcelain/ceramic crowns (D6065) and an abutment supported cast metal crown 
(predominantly base metal) (D6063) for tooth 31.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF care is not medically necessary and your needs can be met in other settings 
such as a skilled nursing facility, at home with home health services or at home with outpatient therapy. 
 
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 that while you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program such as 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 complete series of intraoral x-rays (D0210) provided on 
January 19, 2022. 
 
You asked the Plan to pay for the complete series of intraoral x-rays. You say that you were told by the Plan 
and provider that this treating provider was in-network. You also say that you would like to be reimbursed for 
the services. 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 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 
complete series of intraoral x-rays (D0210) provided on January 19, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued home health care beyond June 3, 2022. 
 
You asked the Plan to pre-approve home health care. You say that you need to have your lung drained once per 
week and are homebound. The Plan denied your request. The Plan says the denial of authorization for 
continued home health care is correct. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health care. Our reviewer says 
that you do not meet the Medicare criteria for continued home health care. Our physician reviewer found there 
is no documentation that further skilled nursing services are required to effectively provide treatment, care, or 
services in order to improve your condition or to establish/perform a maintenance program. Your family has 
been adequately educated in the process of performing the weekly catheter drainage and 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 home health care have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued home health care beyond June 3, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the thorax. 
 
You asked the Plan to pre-approve CT scan. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of authorization for this service is correct, because a similar study 
was already approved and the Plan needs the results of that study to show the need for repeat imaging. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan. Our reviewer says that the 
enrollee does not meet the Medicare criteria for this CT scan. Our physician reviewer found a prior CT scan 
was performed on January 25, 2022, and the records provided do not show that the scan requires follow-up 
imaging or that the mass has grown, changed, or become more symptomatic to require additional imaging. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a computed tomography (CT) scan of the thorax.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the group 3 power wheelchair (PWC) with related 
accessories and features.  
You asked the Plan to pre-approve the group 3 power wheelchair with related accessories and features. You say 
that the items are medically necessary. The Plan denied your request. The Plan says the items are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that all criteria listed in the Medicare Rules section must 
be met for the items to be 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 group 3 power wheelchair with 
related accessories and features. Our reviewer says that the items are not medically necessary. Our physician 
reviewer found the member does not have a neurologic disorder with functional deficits and the documentation 
does not indicate that the member has any pressure injuries or requires intermittent catheterization of the 
bladder that would necessitate power tilt or recline. 
 
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 group 3 power wheelchair with related accessories and features have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the group 3 power wheelchair 
(PWC) with related accessories and features.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF care is not medically necessary as the enrollee is not stable for transfer and the 
enrollee's needs can be met 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that while the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program such as 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services provided on May 17, 2021. 
 
You asked the Plan to pay for the services provided. You say that the claim denied incorrectly. The Plan denied 
your request. The Plan says the service is a duplicate. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 We looked at the file and the rules. The records show that 10 units of CPT code 64450 were billed and paid for 
over 2 separate claims. The claim at issue billed an additional 10 units of CPT code 64450. Claim lines that 
have been determined to be exact duplicates of another claim are denied. Based on this information, we decided 
that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does 
not have to pay for the injection services provided on May 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 25, 2021. 
 
You asked the Plan to pay for the services provided. You say that the specimens received are from providers 
and are irreplaceable. The Plan denied your request. The Plan says the billed codes cannot be verified. 
 
 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. The claim in this case was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. Based on this information, we decided 
that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does 
not have to pay for the lab services provided on August 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an InPen. 
 
You asked the Plan to pre-approve an InPen. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve an InPen.  
 
Benefits for an InPen 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from November 12, 2021, 
through December 11, 2021. 
 
You asked the Plan to pay for the home health services. You say that the services are medically necessary and 
should be paid. The Plan denied your request. The Plan says the date range reported on this claim is not 30 days 
as required. 
 
The Plan must follow Medicare rules. Medicare rules say that the unit of payment for HH PPS is a 30-day 
episode of care. 
 
We looked at the file and Medicare rules. In this case, the claim is for a 29-day episode of care. The from date 
on the claim should be December 12, 2021, in order to correspond to a 30-day episode. Based on this 
information, we decided that Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to pay for the home health services provided from November 
12, 2021, through December 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS procedure. 
 
You asked the Plan to pre-approve CardioMEMS. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of authorization for this service is correct, because this has 
not been proven safe and effective for any indication. 
 
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 CardioMEMS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS procedure would not be considered appropriate and necessary in the enrollee's clinical 
management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the CardioMEMS procedure.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient admission provided from December 1, 2021, to December 
15, 2021. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that you would like a re-evaluation of 
the denied days for inpatient acute care as argument exists for medical necessity. The Plan denied your request. 
The Plan says that the inpatient admission provided from December 4, 2021, to December 10, 2021 was not 
medically necessary. 
 
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 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 inpatient admission provided from December 1, 2021, to December 15, 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.