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

 
We decided that the Plan has to pre-approve the core buildup, including any pins when required (D2950) for 
tooth #15. 
 
You asked the Plan to pre-approve the dental service. You say that you are appealing for the precertification 
that was partially approved. The Plan denied your request. The Plan says that your benefit for the requested 
item or service has already been exhausted. 
 
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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Therefore, we decided that the Plan has to pre-approve the core buildup, including any pins when 
required (D2950) for tooth #15.  
 
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 laboratory services related to end-stage renal disease 
(ESRD) provided on June 6, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on June 6, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Oxygen concentrator (E1390), provided on April 19, 
2022. 
 
You asked the Plan to pay for the Oxygen concentrator. You say that the item should be covered. The Plan 
denied your request. The Plan says the item obtained by the member was rendered by a provider who is not 
under contract with the health plan and is not certified for Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the Oxygen concentrator (E1390), 
provided on April 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87798 billed for date of service March 29, 
2022. 
 
You asked the Plan to pay for procedure code 87798. 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 code 87798 is 13. The MAI value for this code is 3. You billed 23 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 87798 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 87798 billed for date of service March 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular pathology procedure (81479) provided on May 
26, 2022. 
 
You asked the Plan to pay for the molecular pathology procedure. You say that this service was medically 
necessary. The Plan denied your request. The Plan says the requested test is not medically reasonable or 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that covers this NGS testing when the enrollee 
has either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer and has not been previously tested with the same test using NGS for the same cancer genetic content. 
 
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 molecular pathology procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the enrollee has Stage II, not stage III/IV disease. Molecular profiling 
is not medically necessary as it will not lead to an actionable therapy.  
 
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 molecular pathology procedure have not been met. Therefore, we decided 
that the Plan does not have to pay for the molecular pathology procedure (81479) provided on May 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service July 26, 
2022. 
 
You asked the Plan to pay for procedure code 83789. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 83789 is bundled into payment for code G0480. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules state that providers may bill services 
with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.  In this case, 
we have confirmed that code 83789 is a column II code to column I code G0480. While code 83789 was billed 
with modifier -59, the documentation does not support that the service billed with the -59 modifier is a distinct 
procedural service. Code 83789 represents validity testing to confirm the results of the drug tests performed. 
However, Medicare rules say that providers performing validity testing on urine specimens utilized for drug 
testing should not separately bill the validity testing. 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 83789 billed 
for date of service July 26, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) 
provided on July 20, 2022. 
 
You asked the Plan to waive the copayment for MRI. You say that you were not aware of any copayment and 
paying for this service would cause financial strain. 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 $350 
copayment per day for other Medicare-covered diagnostic radiology services that are not ultrasounds. You will 
only pay one copayment per day even if multiple diagnostic radiology services are performed.  
 You have been asked to pay $280.42, which is less than the standard $350 copayment for an MRI. This MRI 
falls within the Outpatient diagnostic tests and therapeutic services and 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 to waive the copayment for magnetic resonance imaging (MRI) provided on July 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Queen Mattress and Platinum Service Plan, provided on 
June 29, 2021. 
 
You asked the Plan to pay for the Queen Mattress and Platinum Service Plan. You say that the item should be 
covered. The Plan denied your request. The Plan says the item was obtained through a provider that is not 
enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the Queen Mattress and Platinum 
Service Plan, provided on June 29, 2021.
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. You say that the enrollee is stable and ready to move 
on to the next level of care. You say that the enrollee exceeds the Medicare criteria for an appropriate 
admission. The Plan denied your request. The Plan says the LTACH is not medically necessary, and the 
enrollee's needs can be met at a lower level of care such as a skilled nursing facility (SNF). 
 
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 was admitted with altered mental status in the setting of empyema 
requiring decortication. The record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services. The enrollee continues to receive acute care services, and these have not been 
denied.  
 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: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve home health services. 
 
You asked the Plan to pre-approve home health services. You say that the services are necessary. The Plan 
denied your request. The Plan says that the services are not medically necessary. 
 
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 services. Our reviewer 
says that the services are medically reasonable and necessary. Our physician reviewer found you are presently 
home bound due to your dementia requiring a considerable and taxing effort to leave home. You have been 
dehydrated and you are potentially unstable with exacerbation of your dementia. You require assessment and 
skilled services to prevent further decline or exacerbation of her dehydration. 
 
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 services have been met. Therefore, we decided that the Plan has to 
pre-approve home health services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid or assistive listening 
device/supplies/accessories (V5267) provided on June 17, 2022. 
 
You asked the Plan to pay for the hearing aid accessories. You say that you were told the services would be 
covered. The Plan denied your request. The Plan says this service is only covered when purchased through the 
Plan's hearing vendor. The Plan also says they confirmed that there were no calls to confirm coverage prior to 
the date-of-service. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased through the Plans hearing aid vendor. 
 
We looked at the file and the Plan's rules. The hearing aid accessory was not purchased through the Plans 
hearing aid vendor. Based on this information, we decided that the Plan's rules for coverage of the hearing aid 
or assistive listening device/supplies/accessories have not been met. Therefore, we decided that the Plan does 
not have to pay for the hearing aid or assistive listening device/supplies/accessories (V5267) provided on June 
17, 2022.  
 Your complaint about potentially receiving misinformation from a plan representative is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on July 1, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on July 1, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee scooter. 
 
You asked the Plan to pre-approve a knee scooter. You say that the services are necessary. The Plan denied 
your request. The Plan says the item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that medically necessary services are those that are 
reasonable and necessary for the diagnosis or treatment of an illness or injury. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a knee scooter have not been met. Therefore, we decided that the Plan does not have to pre-
approve a knee scooter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on May 12, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on May 12, 
2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve Piflufolastat F-18. 
 
You asked the Plan to pre-approve Piflufolastat F-18. You say that the services are necessary. The Plan denied 
your request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Piflufolastat F-18 injections are covered when 
specific 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 Piflufolastat F-18. Our reviewer says 
that the services are medically necessary. Our physician reviewer found the enrollee has had metastatic lesions 
which were seen only with the positron emission tomography/computed tomography (PET/CT) at initial 
staging and the pharmaceutical used was Piflufolastat. Some of these metastatic deposits were not evident on 
conventional imaging. The enrollee's prostate-specific antigen (PSA) has declined from 585 to a minimal level 
greater than 0.05. This agent was approved by the FDA in 2021 and is used when there is suspicion of tumor 
recurrence. This enrollee has known multicentric metastatic disease so even though the PSA has markedly 
declined the probability of residual metastatic disease is great. Since Piflufolastat was used at the initial staging 
it makes sense to use that same agent for the PET/CT already approved in order to determine the 
success/failure of the therapy the enrollee has received over the past year. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Piflufolastat F-18 have been met. Therefore, we decided that the Plan has to 
pre-approve Piflufolastat F-18.  
 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 acute inpatient rehabilitation facility (IRF) admission and 
services. 
 
You asked the Plan to pay for IRF care. You say that the enrollee needs IRF care. The Plan denied your 
request. The Plan says 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 pay for 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 the complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in 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 pay for 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 subsequent nursing facility care (99307 and 99308) 
provided on May 12, 2022, and May 19, 2022. 
 
You asked the Plan to pay for procedure codes 99307 and 99308. 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. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Beginning with dates of service on and after January 1, 2021, the limit for nursing facility care services is one 
telehealth visit every 14 days. 
 
We looked at the file and Medicare rules. The file shows that the Plan paid for a claim submitted with 
procedure code 99309 with date of service May 6, 2022, for this enrollee. This means the subsequent services 
on May 12, 2022, and May 19, 2022, billed with codes 99307 and 99308 are not allowed as they are within the 
14 days of the original code 99309 payment. These codes are not payable when used with POS code 02, for 
telehealth visits. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility 
care (99307 and 99308) provided on May 12, 2022, and May 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 27096 billed for date of service July 9, 2021. 
 
You asked the Plan to pay for procedure code 27096. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 In this case, the MUE for CPT code 27096 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 27096 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 27096 billed for date of service July 9, 2021.