Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Hypoglossal Nerve Stimulator for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that the enrollee cannot tolerate a CPAP mask. The 
Plan denied your request. The Plan says that a CPAP trial has not been attempted. 
 
The Plan must follow Medicare rules. Medicare rules say that FDA-approved hypoglossal nerve 
neurostimulation is considered medically reasonable and necessary for the treatment of moderate to severe 
obstructive sleep apnea when the beneficiary has documentation that demonstrates CPAP failure.  
 
We looked at the file and Medicare rules. The file indicates that the enrollee has not had a trial with a CPAP. 
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 a Hypoglossal Nerve Stimulator for the 
enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral device. 
 You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says the 
device is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that oral appliances are only covered under certain 
medical indications.   
 
The file shows that a SnoreRX oral appliance was requested to treat snoring. We looked at the file and 
Medicare rules. Oral appliances are covered when treating obstructive sleep apnea. Based on this information, 
we decided that Medicare rules for coverage of the requested device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an oral device.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for paramedic intercept services (A0432) provided on November 
20, 2021. 
 
You asked the Plan to pay for paramedic intercept. You say that these services were medically necessary and 
you do not have control over how the ambulance companies provide services. The Plan denied your request. 
The Plan says paramedic intercept services are not covered by Medicare except under certain conditions. A 
claim was submitted to and paid by the Plan for the services provided by the first ambulance company. The 
second company does not have a contractual arrangement with the first company, and therefore is not allowed 
to bill the Plan for the services provided. The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. Medicare allows ALS 
paramedic intercept services only when the services are furnished under a contract with a qualified basic life 
support (BLS), the provision of medically necessary supplies and services, with a volunteer ambulance 
company. In addition, State law must not allow the volunteer ambulance company to bill for the transport or 
BLS services. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. In addition, the Plan has confirmed that there is no contract between these 
two providers. Therefore, we decided that the Plan does not have to pay for paramedic intercept services 
(A0432) provided on November 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric hospitalization from 
January 10, 2022 forward. 
 
You asked the Plan to pre-approve the continued inpatient psychiatric hospitalization. You say that you would 
like reconsideration because the continued inpatient services are medically necessary. The Plan denied your 
request. The Plan says the enrollee's needs can be safely met in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the continued inpatient psychiatric 
hospitalization. Our reviewer says that this enrollee did not require inpatient mental health treatment beyond 
the dates in question as he was not a danger to himself or others and did not have any delusions, auditory or 
visual hallucinations. Our physician reviewer found it did not appear that active treatment was taking place 
beyond the date in question. It did not appear that the services for the dates in question were reasonably 
expected or medically necessary to improve the enrollees condition or for the purpose of diagnosis. This 
enrollee was treated under an individualized treatment plan found in the record. It appears that the services 
were supervised and evaluated by a physician. 
 
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 continued inpatient psychiatric hospitalization have not been met. 
Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric 
hospitalization from January 10, 2022 forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431) provided on 
August 3, 2021, and the bone replacement graft (D7953), diagnostic consultation (D9310), biologic materials 
to aid in soft and osseous tissue regeneration (D4265) and surgical implants (D6010) provided on August 27, 
2021. 
 
You asked the Plan to pay for the dental services. You say that these services should be covered under your 
dental and medical benefits as they are necessary and costly. The Plan denied your request. The Plan says these 
services are not covered by your dental benefit. The Plan also says that they are addressing your quality 
concerns as a separate grievance. 
 
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 services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or 
services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the adjunctive pre-diagnostic test (D0431) provided on August 3, 2021, and the bone replacement graft 
(D7953), diagnostic consultation (D9310), biologic materials to aid in soft and osseous tissue regeneration 
(D4265) and surgical implants (D6010) provided on August 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiofrequency ablation for sacroiliac joint pain (CPT code 
64625) provided on November 4, 2021. 
 
You asked the Plan to pay for the services. You say that this treatment has proven to be beneficial and is 
necessary as the enrollee's quality of life is now suffering and it is beginning to require assistance with 
activities of daily living (ADLs). The Plan denied your request. The Plan says radiofrequency ablation used 
for sacroiliac joint pain is considered not medically necessary/investigational whether performed using 
traditional, cooled, or pulsed radiofrequency. 
 
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 physician reviewer found 
this procedure is considered experimental/ investigational due to the wide variation in efficacy published in the 
peer reviewed literature. Therefore, the procedure was not medically reasonable or necessary. 
 
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 radiofrequency ablation for sacroiliac joint pain (CPT code 64625) provided on November 4, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for the full-face mask use with positive airway pressure 
device (CPT code A7030), CPAP device (E0601), and DME, miscellaneous (E1399) purchased on December 
29, 2021, by a provider not certified with Medicare. 
 
You asked the Plan to reimburse for the DME. You say that you are requesting reimbursement of services 
rendered. The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
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 DME have not been met. This online store is not a Medicare 
contracted DME provider. The Plan only covers the DME purchase if the DME supplier is enrolled in 
Medicare. Therefore, we decided that the Plan does not have to reimburse for the full-face mask use with positive airway pressure device (CPT code A7030), CPAP device (E0601), and DME, miscellaneous (E1399) 
purchased on December 29, 2021, by a provider not certified with Medicare.
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 you need to get strength on your left side so you can 
transfer yourself. The Plan denied your request. The Plan says the IRF services you are requesting do not meet 
the requirements for approval. 
 
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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient rehabilitation stay with an interdisciplinary approach to rehabilitation care. Our 
reviewer also found that while you may benefit from physical therapy and occupational therapy, your 
rehabilitation needs can be addressed at a low intensity alternate 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the enrollee does not 
have transportation available. The Plan denied your request. The Plan says the benefit for routine transportation 
has been exhausted. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 20 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam CT, resorbable collagen placement, 
therapeutic drug injection, and amide local anesthetic provided from January 29, 2021, to July 26, 2021. 
 
You asked the Plan to pay for the dental services. You say that you paid for these services out of pocket. You 
also say that you were advised you would be reimbursed for the services. The Plan denied your request. The 
Plan says the claim was denied correctly. 
 
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 dental services you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone 
beam CT, resorbable collagen placement, therapeutic drug injection, and amide local anesthetic provided from 
January 29, 2021, to July 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for four oral/facial photographic images (D0350) provided on 
August 3, 2021, oral hygiene instructions (D1330) provided on August 17, 2021, and an unspecified oral 
surgery procedure (D7999) provided on August 27, 2021. 
 
You asked the Plan to pay for the dental services. You say that these services were necessary and a terrible 
ordeal, and you feel that your medical insurance should cover what your dental insurance does not. You cannot 
afford all of the treatment you need. The Plan denied your request. The Plan says these services are not covered 
by your dental benefit. The Plan also says your quality concerns are being addressed in a separate grievance 
case. 
 
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 services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or 
services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for four oral/facial photographic images (D0350) provided on August 3, 2021, oral hygiene instructions 
(D1330) provided on August 17, 2021, and an unspecified oral surgery procedure (D7999) provided on August 
27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power wheelchair and related accessories, to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the power wheelchair and related accessories. You say that the items should 
be covered. The Plan denied your request. The Plan says there are in-network suppliers that can provide these 
items. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. The Plan has agreed to pre-approve the requested equipment if provided by an in-network provider. Therefore, we decided that the Plan does not have to pre-approve the 
power wheelchair and related accessories, to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular pathology testing (CPT code(s): 81206, 81275, 
81276, and 81301) provided on November 9, 2021. 
 
You asked the Plan to pay for molecular pathology testing. You say that the claim should be paid. 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. 
 
The denial remains upheld as non-covered as Medicare denies coverage when a laboratory assays two or more 
genes in a patient in parallel. Those two or more genes will be considered part of the same panel. A panel 
constitutes a single procedural service, so one CPT code must be submitted for the panel. Therefore, we 
decided that the Plan does not have to pay for the molecular pathology testing (CPT code(s): 81206, 81275, 
81276, and 81301) provided on November 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81191, 81317, 81321, 
81206, 81210, 81235, 81272, 81275, 81276, 81292, 81295, 81298, 81301, 81311) provided on July 29, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
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 laboratory services have not been met. Review of the file shows 
the member had molecular pathology testing on July 29, 2021. The denial remains upheld as non-covered as 
Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. Those two or 
more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one 
CPT code must be submitted for the panel. 
 
CPT code(s): 81191, 81317, 81321, 81295, 81298, remain not supported. The place of service on the CMS-
1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted 
claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted 
medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 
11; therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain additional 
information from the provider. Therefore, we decided that the Plan does not have to pay for the laboratory 
services (CPT code(s): 81191, 81317, 81321, 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81295, 
81298, 81301, 81311) provided on July 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oxygen concentrator and a portable gaseous oxygen 
system.  
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there was no qualifying blood gas study on exertion from the provider. 
 
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet 
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would 
benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify 
for oxygen solely based on blood gas studies obtained during sleep.   
 
To qualify for home oxygen, the patient must meet one of the following blood gas levels: 
 
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 
 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during 
sleep for a patient who have hypoxia symptoms during sleep;  
 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for 
patients who have hypoxia symptoms during exercise; 
 
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of 
dependent edema, pulmonary hypertension, or erythrocythemia. 
 
For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, 
there is a rebuttable presumption of non-coverage. 
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found supplemental 
oxygen is considered not medically necessary. You have chronic obstructive pulmonary disease, and required 
supplemental oxygen in 2016. However, more recent oximetry at rest shows adequate oxygenation breathing 
room air at rest. There are no measurements of oxygenation during activity or sleep. 
 
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 pre-approve an oxygen concentrator and a portable gaseous oxygen system.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81206, 81275, 81276, 
81301, 81162, 81292, 81295, 81298, 81317, 81404, and 81194) provided on June 2, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
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 laboratory services have not been met. If a laboratory assays 
two or more genes in a patient in parallel, then those two or more genes will be considered part of the same 
panel. A panel constitutes a single procedural service, so one HCPCS code must be submitted for the panel. 
 
CPT code(s); 81162, 81292, 81295, 81298, 81317, 81404, and 81194, remain not supported. The place of 
service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was 
obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; 
however, the submitted medical documentation and/or claim history indicates that the specimen was obtained 
in an office setting POS 11; therefore, the billed code cannot be verified. It is noted multiple attempts were 
made to obtain additional information from the provider. Therefore, we decided that the Plan does not have to 
pay for the laboratory services (CPT code(s): 81206, 81275, 81276, 81301, 81162, 81292, 81295, 81298, 
81317, 81404, and 81194) provided on June 2, 2021.