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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that this admission is medically necessary. The Plan 
denied your request. The Plan says SNF care 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not require skilled nursing services.  
You may benefit from skilled therapy services, but the documentation does not support that it is medically 
necessary to provide these skilled services on a daily basis on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair (K0003). 
 
You asked the Plan to pre-approve the manual wheelchair. You say that the wheelchair is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a manual wheelchair is covered when the beneficiary 
has sufficient upper extremity function and other physical and mental capabilities needed to safely self-propel 
the manual wheelchair that is provided in the home during a typical day. 
 
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 manual wheelchair. Our reviewer 
says that the wheelchair is not medically necessary. Our physician reviewer found a review of the supplied 
documentation that the beneficiary cannot self-propel in a standard wheelchair in the home. 
 
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 manual wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a manual wheelchair (K0003).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services (90837) provided on June 15, 
2021. 
 
You asked the Plan to pay for the psychotherapy 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. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's 
attending or primary care physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy services have not been met. Specifically, the provided records do not document an attempt to consult with, nor a referral from, the 
enrollee's attending or primary care physician. Therefore, we decided that the Plan does not have to pay for the 
psychotherapy services (90837) provided on June 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says step therapy criteria have not been met. 
 
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 Evenity. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the record indicates 
that the enrollee has osteoporosis. The requested medication is a new start. The provided records do not 
indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not 
indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred 
step one alternative. Stage III kidney disease is not prohibitive condition for the use of the plan's preferred 
alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be 
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 Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve e health aide services. 
 
You asked the Plan to pre-approve home health aide services. You say that home health aide services are 
medically necessary. The Plan denied your request. The Plan says the criteria for home health aide services 
have not been met. 
 
The Plan must follow Medicare rules. The rules say that HHA services must be provided on a part time or 
intermittent basis and they must be requested as visits per day.  
 
We looked at the file and Medicare rules. In this case, these services are not requested as part time or 
intermittent basis and are not being requested as visits per day. Based on this information, we decided that Medicare rules for coverage of home health aide services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve e health aide services.
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 enrollee will benefit from acute rehab to optimize 
his level of functioning. The enrollee requires interdisciplinary therapy care to maximize his functional 
potential. The Plan denied your request. The Plan says authorization denied because IRF is not medically 
necessary, and the enrollee's needs can be met at a lower level of care such as skilled nursing facility (SNF). 
 
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 the record shows medical problems are stable and there are no complex nursing 
or rehabilitation needs. The enrollee has a need for physical and/or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this 
enrollee would 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 pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that this should be covered. 
The Plan denied your request. The Plan says that the service is not covered because records indicate that the 
member was a prisoner or in custody of a Federal, State, or local authority when the service was rendered. 
 
The Plan must follow Medicare rules. Medicare rules say that payment may not be made for services furnished 
without charge to individuals who have been committed under a penal statute.  
 
We looked at the file and Medicare rules. The file indicates the enrollee was a prisoner when these services 
were requested. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric 
hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient 
psychiatric hospital services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve desensitizing medicament (D9910), Retainer crown, 
porcelain fused to high noble metal (D6750), Gingival irrigation, per quadrant (D4921), Prefabricated post and 
core in addition to crown (D2954), Core buildup, including any pins when required (D2950) and Pontic, 
porcelain fused to high noble metal (D6240). 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that for this service to be approved the teeth that are holding the bridge 
must have a good long-term outcome. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The documentation provided was incomplete. A specific treatment plan indicating which teeth are being treated and the specific 
abutment retainers and pontics proposed are required. Our physician reviewer found that your condition does 
not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve desensitizing medicament (D9910), Retainer crown, porcelain fused to high noble metal 
(D6750), Gingival irrigation, per quadrant (D4921), Prefabricated post and core in addition to crown (D2954), 
Core buildup, including any pins when required (D2950) and Pontic, porcelain fused to high noble metal 
(D6240).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapy services (97530) provided on October 2, 2021. 
 
You asked the Plan to pay for the therapy 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. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of an OTA shall not be billed as 
services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the 
qualifications of a therapist. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of occupational therapy have not been met. Specifically, the billing provider is a nurse practitioner, 
and not a licensed therapist. As such, OTA services cannot be paid incident to this provider's professional 
services. Therefore, we decided that the Plan does not have to pay for the therapy services (97530) provided on 
October 2, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for future physical therapy (PT) services. 
 
You asked the Plan to reduce the copayments for the PT services. You say that you are having a hard time 
paying the copayments. The Plan denied your request. The Plan says the cost sharing is a fixed amount that 
cannot be waived or reduced. 
 
  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 a $40 
copayment for each physical therapy visit.  
 
According to the EOC, there is a $40 copayment for each visit for PT services. The PT services fall within the 
Outpatient Rehabilitation Services benefit category. 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 reduce the copayments 
for future physical therapy (PT) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete maxillary dentures (D5110) and complete 
mandibular dentures (D5120). 
 
You asked the Plan to pre-approve denture services. You say that you have lost your current set of dentures and 
need these replaced. The Plan denied your request. The Plan says these requested services are not covered 
under your supplemental benefit. 
 
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 pre-approve 
complete maxillary dentures (D5110) and complete mandibular dentures (D5120).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need about two months of care otherwise you 
could fall and hurt yourself. The Plan denied your request. The Plan says you do not meet Medicare criteria for 
coverage. 
 
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 your rehabilitation needs can be met at a lower intensity setting such as in a skilled 
nursing facility.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Computed tomography (CT) scan (70450) provided on 
September 10, 2021. 
 
You asked the Plan to pay for code 70450. 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 70450 
is a column II code to column I code 70496. 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 the Computed tomography (CT) scan (70450) provided on 
September 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for arthrodesis, sacroiliac joint, percutaneous or minimally 
invasive (indirect visualization), with image guidance (27279) surgical supply; miscellaneous (A4649) 
provided August 30, 2021. 
 
You asked the Plan to pay for the procedure. You say that you provided the services to the enrollee in good 
faith with the expectation of payment. The Plan denied your request. The Plan says payment for this service 
would be included in the facility payment and the responsibility of the facility. 
 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 find that CPT code 27279 and A4649 is not supported in the medical record. Specifically, the 
enrollee used the equipment in the facility during and/or after surgery. Payment for this service would have 
been included under the facility claim. Payment for this service is the responsibility of the facility or hospital 
that provided the surgery. Based on this information, we decided that Medicare rules for coverage of the 
procedure have not been met. Therefore, we decided that the Plan does not have to pay for arthrodesis, 
sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance (27279) 
surgical supply; miscellaneous (A4649) provided August 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drainage device insertion (0376T) provided on July 13, 
2021. 
 
You asked the Plan to pay for the drainage device insertion (0376T). The Plan denied your request. The Plan 
says this charge is included in the ambulatory surgical center reimbursement. 
 
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, the CPT Code Manual definition of code 0376T is insertion of anterior segment aqueous drainage 
device, without extraocular reservoir, internal approach, into the trabecular meshwork; each additional device 
insertion (List separately in addition to code for primary procedure).  
We find that CPT code 0376T is not supported in the medical record. Specifically, CPT code 0376T has a 
status indicator of N1. This means that payment for CPT code 0376T is packaged and separate payment cannot 
be issued. Based on this information, we decided that Medicare rules for coverage of the drainage device 
insertion (0376T) have not been met. Therefore, we decided that the Plan does not have to pay for the drainage 
device insertion (0376T) provided on July 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for interrogation device evaluation (remote), up to 90 days 
(93296) provided on October 28, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the interrogation device evaluation. You say that you believe there is some 
discrepancy in the billing. This charge is for a device interrogation regarding your pacemaker. Since the battery 
was running low it was necessary to be checked monthly. The Plan denied your request. The Plan says prior 
authorization is required for prosthetic devices. 
 
Medicare rules say that this PPO plan will generally cover your medical care as long as the care you receive is 
considered medically necessary and you receive your care from a provider who is eligible to provide services 
under Original Medicare. As a member of the PPO Plan you can receive your care from either a network 
provider or an out-of-network provider. The health Plan contract specifically says that a prior authorization is 
required for the services at issue. 
 
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 interrogation device evaluation (remote), up to 90 days (93296) provided on October 28, 2021 by an out-of-network (OON) 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 2, 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 provided on September 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 21, 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 provided on June 21, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the colonoscopy services provided on October 6, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the claim was 
processed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
The file shows that CPT code 45380 was billed with code 45385. The rules say that CPT code 45380 may be 
eligible for payment when billed with this code pair. The records do not show that the service billed with the -
59 modifier is a distinct procedural service. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for the colonoscopy 
services provided on October 6, 2021.