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

 
We decided that the Plan does not have to pre-approve an open MRI of the upper spinal canal. 
 
You asked the Plan to pre-approve an open MRI of the upper spinal canal. You say that you have tried another 
open MRI and it was still to close/closed. You say you couldn't handle it and your heart rate went up. The Plan 
denied your request. The Plan says the requested open MRI is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 an open MRI of the upper spinal canal. 
Our physician reviewer found that the reason for the request for open MRI is not certain, but it appears it is due 
to your obesity with body-mass index (BMI) of 41. It is possible that your body habitus precludes a 
conventional MRI wide bore machine but there is no evidence you have attempted to have such an exam.  If a 
conventional MRI machine can accommodate your body habitus and claustrophobia is an issue, there is no 
evidence you have tried conscious sedation to complete the test. Absent discussion of the above factors, the 
medical necessity of an open MRI examination has not been established in the provided records. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an open MRI of the upper spinal canal have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an open MRI of the upper spinal canal.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 10120 billed for date of service August 15, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the doctor provided services in good faith. The 
Plan denied your request. The Plan says the code billed is not appropriate. 
 
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 10120 is incision and removal of foreign body, 
subcutaneous tissues; simple. 
 
 
 
 We find that CPT code 10120 is not supported in the medical record. Specifically, the medical records do not 
show that the billed procedure was performed. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 10120 billed for date of service August 15, 2022.
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 November 16, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. 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 
November 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0673, E0675) provided 
on September 7, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was medically 
necessary. The Plan denied your request. The Plan says this device was used in a surgical center and was not 
for use in the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for a pneumatic compression device (E0673, E0675) provided on September 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic for tooth #13, and a retainer crown (D6750) for 
tooth #11, #12, and #5. 
 
You asked the Plan to pre-approve the dental services. You say that you would like the Plan to approve this 
dental work. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted with the approval of D6750 for tooth #6, 
and D6240 for tooth #7, #8, #9, and #10. Therefore, we decided that the Plan does not have to pre-approve a 
pontic for tooth #13, and a retainer crown (D6750) for tooth #11, #12, and #5.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), gingival irrigation 
(D4921), an extraction (D7210), and a bone graft (D7953) for tooth #10 provided by an out-of-network 
provider on December 4, 2021. 
 
You asked the Plan to pay for the dental services. You say that it was a dental emergency, and you needed the 
services done immediately. The Plan denied your request. The Plan says the extraction was received from an 
out-of-network provider and are not covered by your supplemental benefits. Also, the denial of authorization 
for the limited oral evaluation, gingival irrigation, and the bone graft is correct because they are not covered by 
the Plan. 
 
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 record shows you received the extraction from an out-of-network provider. Though the Plan offers a dental 
benefit in excess of Medicare coverage, the extraction is not covered under this benefit when received from an 
out-of-network provider. The limited oral evaluation, gingival irrigation, and the bone graft are not covered 
under the Plans dental benefit. Therefore, we decided that the Plan does not have to pay for a limited oral 
evaluation (D0140), gingival irrigation (D4921), an extraction (D7210), and a bone graft (D7953) for tooth #10 
provided by an out-of-network provider on December 4, 2021.
Appeal type: Practitioner Services
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 August 9, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. 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 August 
9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says criteria for admission to the LTACH have 
not been met. 
 
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 all medically necessary care is being provided in the current acute care setting.  
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting.  The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and related 
supplies. 
 
You asked the Plan to pre-approve the CGM and related supplies. You say that you need the CGM to help 
control your blood sugar because it gets high. The Plan denied your request. The Plan says the Medicare 
criteria was not met. 
  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM and 
related supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM) and related supplies.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for Medicare Part B prescription drugs and a 
specialist office visit provided on October 17, 2022. 
 
You asked the Plan to waive the cost share for Medicare Part B prescription drugs and a specialist office visit. 
You say that you disagree with the cost share. 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 a 20% 
coinsurance for Medicare Part B prescription drugs and a $40 copayment for physician/practitioner 
services/specialist.  You have been asked to pay a 20% coinsurance for Medicare Part B prescription drugs and a $40 copayment 
for a specialist office visit. The total allowed amount for the prescription drugs is $1,350.60. You are being 
asked to pay $270.12 ($1,350.60 x 20% = $270.12). You are being asked to pay $30.54 for the office visit 
which is less than the required amount. The total amount you are being asked to pay $300.66 ($270.12 + 30.54 
= $300.66). This item/service falls within the Medicare Part B prescription drugs and physician/practitioner 
services/specialist 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 cost share for Medicare Part B 
prescription drugs and a specialist office visit provided on October 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service September 
19, 2022. 
 
You asked the Plan to pay for procedure code 99223. You say that this service is supported as billed. The Plan 
denied your request. The Plan says the code used to report the services provided is not supported in the medical 
record. 
 
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 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 
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 99223. Our reviewer says that this code is 
not supported in the medical record. Our reviewer found that the records did not support that there was a 
comprehensive history. The records did support that there was a comprehensive exam and medical decision 
making of high complexity. 
 
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 99223 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99223 billed for date of service September 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient mental health care stay 
provided from May 3, 2022, to May 20, 2022. 
 
You asked the Plan to waive the copayment for the inpatient mental health care stay. You say that the claim is 
still in pending status, and you are being contacted about collections for this claim. 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 a $150 
copayment per day for days 1-9 of each inpatient mental health care stay.  
 You have been asked to pay a $150 copayment per day for days 1-9 of the inpatient mental health care stay. 
You have not been charged for any day after day nine. You have been asked to pay a total of $1,350 ($150 
copayment per day x 9 days = $1,350). This item/service falls within the inpatient mental health care 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 the inpatient mental health care stay provided 
from May 3, 2022, to May 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary your complex medical 
needs. The Plan denied your request. The Plan says that you can safely receive the services needed in another 
setting such as at a skilled nursing facility, or home with home health services. 
 
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 you are medically stable. While you may benefit from physical and occupational 
therapy, your rehab needs can be provided in a lower intensity and alternate setting such as in-home with 
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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant 
(D6010) Tooth #22 and 27, attachment abutment (D6052) Tooth #22 and 27 and abutment supported 
porcelain/ceramic crown (D6058) Tooth #22 and 27. 
 
You asked the Plan to pre-approve dental services. You say that you are upset that implants are not covered, 
because it is causing issues with your dentures. The Plan denied your request. The Plan says these services are 
not covered under your Plan. 
  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. Surgical placement of implant 
body: endosteal implant (D6010), attachment abutment (D6052) and abutment supported porcelain/ceramic 
crown (D6058) are not covered under the Plans dental benefits. 
 
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 
surgical placement of implant body: endosteal implant (D6010) Tooth #22 and 27, attachment abutment 
(D6052) Tooth #22 and 27 and abutment supported porcelain/ceramic crown (D6058) Tooth #22 and 27.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PRALUENT (alirocumab) injection. 
 
You asked the Plan to pre-approve PRALUENT (alirocumab) injection. You say that the requested 
PRALUENT (alirocumab) injection is medically necessary. The Plan denied your request. The Plan says the 
requested PRALUENT (alirocumab) injection is a Part D drug. The enrollee does not have Part D benefits 
with the Health Plan. Please notify the Part D provider for precertification. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve PRALUENT 
(alirocumab) injection.  
 
Benefits for PRALUENT (alirocumab) injection may be available under Medicare Part D. Contact the Plan 
that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service September 6, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the claim incorrectly denied as a duplicate. The 
Plan denied your request. The Plan says the enrollee was seen multiple times for the same reason on the date of 
service. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the enrollee was seen by two physicians in the same group practice, of the same specialty on the 
date of service at issue. Instead of billing separately, the physicians should select a level of service 
representative of the combined visits and submit the appropriate code for that level. Based on this information, 
we decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code 99285 billed for date of service September 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for the wound debridement services provided 
from October 11, 2022, to November 15, 2022. 
 
You asked the Plan to reduce the copayments for the wound debridement services. You say that you would like 
to have the lower copayment amount applied to all dates of service. 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 a $298 
copayment for each in-network outpatient surgery.  
 
You have been asked to pay $118.05, which is less than the standard $298 copayment for the wound 
debridement services received on October 11, 2022. You have then been asked to pay a $298 copayment for each wound debridement service received from October 18, 2022, to November 15, 2022. These items/services 
fall within the outpatient surgery 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 reduce the copayments for 
the wound debridement services provided from October 11, 2022, to November 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement hospital bed. 
 
You asked the Plan to pre-approve a replacement bed. You say that the enrollee's current bed is missing pins to 
hold it up. You say that the enrollee was billed for a new bed only a couple of years ago. You say that this bed 
is actually from 2011. You also say that the enrollee requires a bed that is safe. The Plan denied your request. 
The Plan says a replacement bed is not necessary at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that equipment which the beneficiary owns or is a 
capped rental item may be replaced in cases of loss or irreparable damage.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a replacement bed have not been met. The file does not indicate irreparable wear or damage to the 
current bed. Therefore, we decided that the Plan does not have to pre-approve a replacement hospital bed.