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

 
We decided that the Plan does not have to pre-approve kyphoplasty surgery. 
 
You asked the Plan to pre-approve kyphoplasty. You say that it would be in the enrollee's best interests to 
proceed with kyphoplasty. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
this surgery. 
 
The Plan follows Medicare rules. Medicare rules state that kyphoplasty surgery is only covered if certain 
inclusion criteria are met. 
 
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 kyphoplasty. Our reviewer says that the 
enrollee does not meet criteria for kyphoplasty. Our physician reviewer found the enrollee does not meet 
inclusion criteria, as the enrollee does not have a documented osteoporotic compression fracture from the T1-
L5 level. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty surgery.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for bupivacaine (J3490). 
 
You asked the Plan to pay for bupivacaine. You say that this should be paid. The Plan denied your request. The 
Plan says that payment was made according to the Medicare allowable rate. 
 
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. Specifically, the file indicates that this drug was paid for a February 9, 2022, 
date of service. There is no rationale as to why this drug cannot be paid for the date of service in this case. 
Therefore, we decided that the Plan has to pay for bupivacaine (J3490).  
 
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 the cardiac risk assessment genetic screening testing (81238, 
81286, 81407, 81408, 81479) provided on February 14, 2022. 
 You asked the Plan to pay for the cardiac risk assessment genetic screening testing. You say that the testing 
was performed as ordered by the enrollee's provider. The Plan denied your request. The Plan says screening 
tests are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the cardiac risk assessment genetic screening testing, was requested solely for 
screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that 
the Plan does not have to pay for the cardiac risk assessment genetic screening testing (81238, 81286, 81407, 
81408, 81479) provided on February 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 there is no indication that you would require skilled rehabilitation in an IRF, 
participating in rehabilitation services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain your functional status. Your can receive further services at a lower level of 
care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guidance urinary tract infection (UTI) testing provided 
on October 13, 2022. 
 
You asked the Plan to pay for the Guidance UTI. You say that this testing should be covered. The Plan denied 
your request. The Plan says this testing is not covered under Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this 
information, we decided that Medicare rules for coverage of the Guidance UTI have not been met. Therefore, we decided that the Plan does not have to pay for the Guidance urinary tract infection (UTI) testing provided on 
October 13, 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 you are requesting an expedited 
reconsideration for the denial of an LTACH admission as the enrollee currently meets LTACH admission 
criteria. The Plan denied your request. The Plan says the enrollee does not meet the Medicare guidelines for 
care in an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving but requires additional short-term acute care 
services that can safely be administered at the current facility until more stable and appropriate for a lower 
level of care. There are no services at the LTACH that the enrollee requires that are not already available and 
covered at the current facility. Transfer to the LTACH would not be clinically advantageous at this time and 
completion of treatment at the current facility is recommended. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have for additional reimburse for the ostomy skin barrier (A4385) and 
ostomy pouch, drainable (A4389) purchased September 27, 2022. 
 
You asked the Plan for additional reimburse for the ostomy supplies. You say that you point out that you are 
required to pay only 20% and submit this appeal for an additional payment and explanation. The Plan denied 
your request. The Plan says this cost sharing was charged 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 20% 
coinsurance for Medicare covered durable medical equipment and supplies. 
 
You have asked to for additional reimbursement for the ostomy supplies. You received reimbursement of 
$22.13. Page 45 of the EOC also says that a member may pay some additional fees for using the out of network 
option cost sharing. This item/service falls within the Durable medical equipment (DME) and related supplies 
benefit category. 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 for additional reimburse for the ostomy skin barrier (A4385) 
and ostomy pouch, drainable (A4389) purchased September 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture-maxillary (D5110) and a complete 
denture-mandibular (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee cannot eat well and needs their 
teeth. You say the enrollee cannot wait a year. The Plan denied your request. The Plan says the benefit for the 
requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the benefit for the requested item or service was exhausted on date of service November 5, 2019. 
Therefore, we decided that the Plan does not have to pre-approve a complete denture-maxillary (D5110) and a 
complete denture-mandibular (D5120).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 12, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim for this molecular pathology testing did not include the required unique 
identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on 
September 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided out of the country on October 25, 
2021, through November 24, 2021. 
 
You asked the Plan to pay for the dental services provided out of the country. You say that you were in 
Germany and had emergency surgery on an infected and painful tooth. You say that you have coverage for 
$1,000 worth of dental care, which has not been received. You say that you are very low income. The Plan 
denied your request. The Plan says your coverage does not include dental care provided outside of the United 
States of America. 
 
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, dental services provided outside of the 
United States of America are not among those covered under this benefit.   Therefore, we decided that the Plan 
does not have to pay for dental services provided out of the country on October 25, 2021, through November 
24, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service May 13, 
2022. 
 
You asked the Plan to pay for procedure code 99291. The Plan denied your request. The Plan says payment for 
code 99291 is bundled into payment for code 92950. 
 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 99291 
is a column II code to column I code 92950. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99291 billed for date of service May 13, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for an incontinence garment, any type, (e.g., brief, diaper) (code A4520) 
provided on April 22, 2022. 
 
You asked the Plan to pay for the incontinence garment, any type, (e.g., brief, diaper). The Plan denied your 
request. The Plan says that the claim was billed with an invalid/del code, modifier. 
 
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. Specifically, the Plan has not provided a Medicare rule, a Plan rule or a coding 
rule to substantiate their denial. Therefore, we decided that the Plan has to pay for an incontinence garment, 
any type, (e.g., brief, diaper) (code A4520) provided on April 22, 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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the take-home supply of methadone; up to 7 additional day 
supply (provision of the services by a Medicare-enrolled Opioid Treatment Program), List separately in 
addition to code for primary procedure (G2078)} provided on October 10, 2022, by an out-of-network (OON) 
provider. 
 You asked the Plan to pay for then Opioid treatment. You say that you believe that the Plan did not have all the 
necessary information to process your claim correctly. The Plan denied your request. The Plan says enrollees 
must receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Payment is not allowed for this claim because it does not meet the opioid treatment program criteria 
for payment. 
 
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 the take-home supply of methadone; up to 7 
additional day supply (provision of the services by a Medicare-enrolled Opioid Treatment Program), List 
separately in addition to code for primary procedure (G2078)} provided on October 10, 2022, by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a pneumonia vaccine provided on November 15, 2022. 
 
You asked the Plan to pay for the pneumonia vaccine. You say that your doctor ordered the pneumonia 
vaccine. The Plan denied your request. The Plan says that you received a pneumonia vaccine on  
January 3, 2022. The policy has a benefit maximum allowed of 1 per calendar year. 
 
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. Specifically, the Plan has not provided a Medicare rule or a Plan rule to 
substantiate their denial that there is a benefit limit of one pneumonia vaccine per calendar year. Therefore, we 
decided that the Plan has to pay for a pneumonia vaccine provided on November 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.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant surgeon during endoscopy services provided on 
November 18, 2021. 
 
You asked the Plan to pay for the assistant surgeon services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 29848. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid.  
 Based upon this information, we find that Medicare coverage criteria for the assistant surgeon services have not 
been met. Therefore, we decided that the Plan does not have to pay for the assistant surgeon during endoscopy 
services provided on November 18, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from November 8, 2022, 
to November 14, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the 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 November 8, 2022, to 
November 14, 2022.
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 April 7, 
2022. 
 
You asked the Plan to pay for procedure code 99053. You say that you disagree with the denial. 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 April 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on July 28, 
2022. 
 
You asked the Plan to pay for the DecisionDx-SCC test. You say that this testing is medically necessary. The 
Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this 
information, we decided that Medicare rules for coverage of the DecisionDx-SCC test have not been met. 
Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on 
July 28, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the electrical stimulator supplies provided on May 27, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says that charges for or in connection with services or supplies 
that are, as determined by us, considered to be experimental or investigational are excluded from coverage 
under the member's plan. 
 
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. Review of the file does not include a clear explanation of why these items are 
being denied. In addition, no Medicare rules were provided to support the denial of this code. No other denial 
rationale was provided. The Plan did not substantiate their denial. Therefore, we decided that the Plan has to 
pay for the electrical stimulator supplies provided on May 27, 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.