Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infrared therapy (97026) provided on April 6, 2022. 
 
You asked the Plan to pay for the infrared therapy. You say that the services were medically necessary. You 
say that the enrollee presented with very painful low back pain. You also say that this should be reconsidered 
for payment. The Plan denied your request. The Plan says infrared therapy is not reasonable and necessary by 
Medicare and is excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that infrared therapy devices and any related 
accessories is not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the infrared therapy have not been met. Therefore, we decided that the Plan does not have to pay 
for the infrared therapy (97026) provided on April 6, 2022.
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 service is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require skilled nursing or therapy services on a daily basis. The 
enrollee's needs can be met 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 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 wheelchair accessories. 
 You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says the 
services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that wheelchair options and accessories are only 
covered under certain medical indications.  
 
The file shows that a removable under seat pouch, push handles, and 24-inch wheels were requested. We 
looked at the file and Medicare rules. These items do not serve a purpose that is primarily medical in nature. 
Convenience items are not covered. Based on this information, we decided that Medicare rules for coverage of 
the requested items have not been met. 
 
The file shows that an adjustable seat depth was requested. The rules say that payment for seat widths and/or 
seat depths of 15-19 inches is included in the payment for the base code. These seat dimensions should not be 
billed separately. Based on this information, we decided that Medicare rules for coverage of the requested item 
has not been met. 
 
The file shows that backrest options were requested. We looked at the file and the rules. Wheelchair seat and 
back cushion codes are all-inclusive. Use of HCPCS code K0108 or any other HCPCS code to separately bill 
for added components is incorrect coding. Based on this information, we decided that Medicare rules for 
coverage of the requested item has not been met. 
 
The file shows that a tubular footplate was requested. We looked at the file and the rules. The request was 
billed using code K0108. Providers must bill items with the correct codes. Furthermore, footrests are included 
in the basic wheelchair package. There is no documentation that shows why the included footrest is unable to 
meet the enrollees needs. Based on this information, we decided that Medicare rules for coverage of the 
requested item has not been met. 
 
The file shows that a replacement cover for a wheelchair cushion, and a replacement wheel lock assembly were 
requested. We looked at the file and the rules. Replacement items are not covered when billed for initial use. 
Based on this information, we decided that Medicare rules for coverage of the requested item has not been met. 
Therefore, we decided that the Plan does not have to pre-approve wheelchair accessories.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for npatient hospital services provided to the enrollee from 
March 15, 2021, to March 19, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the original claim should have been adjusted by combining the original and subsequent stay into 
a single claim. 
 The Plan follows Medicare Rules. Medicare rules say that inpatient readmission is covered when medically 
necessary, and if the readmission did not result from a premature discharge from the same hospital. 
 
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 services. Our reviewer says that the 
services at issue in this case do not meet the coverage criteria for readmission. Our physician reviewer found 
although the readmission was medically necessary, it did result from a premature discharge from the same 
hospital. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for npatient hospital services provided to the enrollee from March 15, 2021, to March 19, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the genetic testing provided on January 12, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the genetic testing. You say that these services were ordered by the enrollee's 
physician. The Plan denied your request. The Plan says that the services were provided out-of-network and 
were not approved in advance. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the genetic testing by a contract provider. The file does not show that the plan 
provided notice that the genetic testing would not be covered. Under Medicare rules, this means the genetic 
testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for the genetic 
testing provided on January 12, 2022, by an out-of-network (OON) provider.  
 
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 rendered on February 23, 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 services are not covered. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on February 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87640 billed for date of service November 
15, 2021. 
 You asked the Plan to pay for procedure code 87640. You say that these services were necessary and are 
supported in the medical records. The Plan denied your request. The Plan says they have agreed to pay for the 
other lab services; however, procedure code 87640 is not supported for separate payment. 
 
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 87640 is a column II code to column I code 87641; however, 87640 
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 procedure code 87640. Our reviewer says that code 87640 is 
not supported for separate payment. Our reviewer found the laboratory report includes documentation of 
procedures performed on a single specimen. In this case, code 87641, Staphylococcus aureus, methicillin 
resistant, includes Staphylococcus aureus. Therefore, billing CPT 87640 would not be appropriate in this case. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 87640 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87640 billed for date of service November 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87640, 87653 and 87798 billed for 
date of service September 17, 2021. 
 You asked the Plan to pay for procedure codes 87481, 87640, 87653 and 87798. You say that these services 
were necessary and are supported as billed. The Plan denied your request. The Plan says the payment for codes 
87481, 87640, 87653 and 87798 is bundled into payment for code 87801. 
 
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 codes 
87481, 87640, 87653 and 87798 are each column II codes to column I code 87801. These services have 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 codes 
87481, 87640, 87653 and 87798 billed for date of service September 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical extractions (D7210) of tooth #'s 21, 22, 23, 26, 
27, 28, and 29. 
 
You asked the Plan to pre-approve the surgical extractions. The Plan denied your request. The Plan says the 
provider did not submit any narrative or x-ray information to support the medical necessity of the above 
proposed treatments. The Plan also says without any information, there is no way to know if these procedures 
are necessary. 
 
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. The Plan covers the surgical 
extractions when the services are medically necessary and reasonable.  
 
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 surgical extractions. Our reviewer 
says that the documentation provided does not support the need for surgical extractions (D7210) for tooth #'s 
21, 22, 23, 26, 27, 28 and 29 Our physician reviewer found there was no narrative as to why the extractions 
were needed, nor why surgical rather than extractions via forceps and elevation (D7140) are needed.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the surgical extractions have not been met. Therefore, we decided that the Plan 
does not have to pre-approve surgical extractions (D7210) of tooth #'s 21, 22, 23, 26, 27, 28, and 29.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device (33289). 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says the requested device is considered experimental and 
not covered at this time. 
 
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 the CardioMEMS device. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is a lack of studies examining long-term clinical outcomes establishing the 
value of CardioMEMS in patient management. More research is needed to show safety and efficacy. 
 
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 CardioMEMS device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a CardioMEMS device (33289).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extractions (D7210 and D7140) provided by an out-of-
network provider on May 6, 2022. 
 
You asked the Plan to pre-approve extractions. You say that these services were provided because of an 
emergency. The Plan denied your request. The Plan says these services have been correctly denied. 
 
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 
extractions (D7210 and D7140) provided by an out-of-network provider on May 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0117U) provided January 14, 2022. 
 
You asked the Plan to pay for the lab services. You say that this test was medically necessary. The Plan denied 
your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that to report a Molecular Diagnostic Test service, 
providers must include the appropriate DEX Z-code. 
 
We looked at the file and Medicare rules. An appropriate DEX Z-code was not submitted with the claim. Based 
on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for lab services (0117U) provided January 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a special cushion (molded distal cushion) and extra knee 
suspension. 
 
You asked the Plan to pre-approve a special cushion (molded distal cushion) and extra knee suspension. You 
say that you feel the Plan should overturn the decision. The Plan denied your request. The Plan says you do not 
meet criteria for the requested items. 
 
The Plan follows Medicare rules. The rules say that Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and 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 a special cushion (molded distal 
cushion) and extra knee suspension. Our reviewer says that the documentation supports that the requested items 
are duplicate items. Our physician reviewer found you have a past medical history of left below the knee 
amputation with K3 level capabilities. The documentation supports that the requested items are considered 
duplicative and therefore, are not covered. 
 
We looked at this physician's review, the file, and Medicare rules. The documentation shows that you currently 
have the requested items. This means that the request is for duplicate items. Based on this information, we 
decided that Medicare rules for coverage of a special cushion (molded distal cushion) and extra knee 
suspension have not been met. Therefore, we decided that the Plan does not have to pre-approve a special 
cushion (molded distal cushion) and extra knee suspension.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve addition, endoskeletal system, above knee, flexible 
protective outer surface covering system (CPT code L5964). 
 
You asked the Plan to pre-approve the protective outer surface covering. You say that the item is necessary. 
The Plan denied your request. The Plan says there is no documentation that supports that your activity subjects 
you to harsh environmental situations or that you engage in any extraordinary activities that would justify the 
need for extra protection with a flexible outer surface covering system. 
 
 
 
 
 
 
 
 
 The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the protective outer surface covering have not been met. There is 
no documentation that supports that your activity subjects you to harsh environmental situations or that you 
engage in any extraordinary activities that would justify the need for extra protection with a flexible outer 
surface covering system. Therefore, we decided that the Plan does not have to pre-approve addition, 
endoskeletal system, above knee, flexible protective outer surface covering system (CPT code L5964).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient services provided from August 1, 2021, through August 14, 
2021, at DRG 854. 
 
You asked the Plan to pay for inpatient services at DRG 854. You say that the medical records clearly support 
the clinical diagnosis and DRG assignment as billed. You say that payment of the entire claim should be 
approved. The Plan denied your request. The Plan says that the sepsis diagnosis has been removed which 
downgraded the DRG from 854 to 580. 
 
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, medical records were not submitted to determine that the diagnosis 
of sepsis is not supported. This means that we cannot determine if the DRG downgrade is correct. It is the 
burden of the Health Plan to substantiate their denial with evidence. In this case, the denial has not been 
substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for inpatient 
services provided from August 1, 2021, through August 14, 2021, at DRG 854.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bi-directional progressive stretch knee device with 
range of motion adjustment, includes cuffs (E1811). 
 
You asked the Plan to pre-approve a progressive stretch knee device. You say that this is a billable code per 
CMS. This has been eligible /valid since 1/1/2002. The Plan denied your request. The Plan says patient-
controlled stretching devices are investigational. There is not enough expert-reviewed proof in scientific 
journals to verify this device would be beneficial to the member's condition. The member's benefit plan does 
not cover investigational services or devices. 
 
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 a progressive stretch knee device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no documentation that the requested device meets Medicare 
criteria. Provided records and review of the literature do not document that the requested device improves 
health outcomes for a diagnosis of osteoarthritis and stiffness of the knees. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a progressive stretch knee device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a bi-directional progressive stretch knee device with range of motion 
adjustment, includes cuffs (E1811).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
January 16, 2022. 
 
You asked the Plan to waive the copayment for ambulance transportation. You say that this ambulance ride 
was not your choice. The Plan denied your request. The Plan says the copayment amount you are being 
charged is correct. 
 
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 $275 
copayment for each one-way ambulance trip.  
 
You have been asked to pay $275 copayment for ambulance transportation. Ambulance transportation falls 
within the Ambulance Services 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 
ambulance transportation provided on January 16, 2022.