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

 
We decided that the Plan does not have to pre-approve Synthroid for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that this is not covered under Part B. 
 
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 Synthroid for the enrollee.  
 
Benefits for this drug 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 83789-59 billed for date of service July 21, 2021.
You asked the Plan to pay for procedure code 93789-59. You say that this testing was medically necessary. The
Plan denied your request. The Plan says the use of the -59 modifier for code 83789 is not supported. This code
is not separately reimbursed when billed for specimen validity testing on urine specimens utilized for drug
testing. This is not a separately identifiable service.
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the
service billed with the modifier indicates a distinct procedural service.
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 procedure code 83789-59. Our reviewer says
that usage of the -59 modifier is not supported by the medical record. Our physician reviewer found the -59
modifier should be used to represent a different session or patient encounter, different procedure or surgery,
different site, or organ system, separate incision/excision, or separate injury. A distinct procedural service is not
supported by the documentation in the case file. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 83789-59 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 83789-59 billed for date of service July 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) and four 
periodontal scalings and root planings (D4341 x4) provided on September 15, 2021, and September 27, 2021. 
 
You asked the Plan to pay for the comprehensive periodontal evaluation and periodontal scalings and root 
planings. You say that these services were medically necessary. The Plan denied your request. The Plan says 
these services are not covered benefits under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 pay for the 
comprehensive periodontal evaluation (D0180) and four periodontal scalings and root planings (D4341 x4) 
provided on September 15, 2021, and September 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography (CT) scan provided to the enrollee on August 30, 2021.
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your request. The Plan says this is a packaged 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. In this case, the CPT Code Manual definition of code 72125 is "Computed tomography, cervical spine; without contrast material." 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 the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found CPT 72125 is a packaged service with 70450 and 71250. We looked at this coder'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 a computed tomography (CT) scan provided to the enrollee on August 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 8, 2021.
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 genetic testing procedures submitted under CPT code 81455 are denied as not medically necessary. We looked at the file and Medicare rules. The services are billed under code 81455. 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 pay for the laboratory services rendered on October 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a porcelain/ceramic crown (D2740) provided on November 2, 2021. 
 
You asked the Plan to pay for a crown. You say that you do not agree with the denial. The Plan denied your 
request. The Plan says the dental allowance had been met for the year. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
We looked at the file and Medicare rules. The records show that prior to your date of service on November 2, 
2021, you had used $605 of your $1,500 dental allowance. The records also show that the Plan processed your 
claim for November 2, 2021 and applied $895 of your remaining allowance available, therefore, you exhausted 
your $1,500 dental allowance for 2021. You are responsible for any amount over the allowance amount. Based 
on this information, we decided that the Plan's rules for coverage of a crown have not been met. Therefore, we 
decided that the Plan does not have to pay for a porcelain/ceramic crown (D2740) provided on November 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a drug screening to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve a drug screening. You say that your doctor was sending you to the provider. 
The Plan denied your request. The Plan says the provider that the enrollee is requesting to see is an out-of-
network provider and there are several in-network laboratories that provide the same service. 
 
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. Therefore, we decided that the Plan does not have to pre-approve 
a drug screening to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic procedure (CPT code 97110) provided on 
August 18, 2021. 
 
You asked the Plan to pay for the therapeutic procedure. You say that the claim should be paid. The Plan 
denied your request. The Plan says the service is not supported by the records. 
 
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 97110 is therapeutic procedure, 1 or more areas, each 15 
minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. 
 
CPT code 97110 GP CQ KX (4 units) remains not supported. CPT code 97110 represents Therapeutic 
procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of 
motion and flexibility, however the records indicate that the service is performed by a physical therapy 
assistant in a home health or hospice setting. Of note there is an appropriate Healthcare Common Procedure 
Coding System (HCPCS) code (G0157) for the billed service. It is noted that multiple attempts were made to 
contact the provider for additional information. Based on this information, we decided that Medicare rules for coverage of the therapeutic procedure have not been met. Therefore, we decided that the Plan does not have to 
pay for the therapeutic procedure (CPT code 97110) provided on August 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic test (D0431), scaling and root planing (D4341 
x 4), localized delivery of antimicrobial agent (D4381 x 6), take home drugs (D9630 x 2), surgical extractions 
(D7210 x 3), immediate partial upper denture (D5221), and fluoride varnish (D1206) provided from June 11, 
2021, to September 30, 2021. 
 
You asked the Plan to pay for the dental services. You say that you already paid the provider. You also say that 
you feel the provider should not have made a claim to insurance. The Plan denied your request. The Plan says 
the services you received are not covered. 
 
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 recieved are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
diagnostic test (D0431), scaling and root planing (D4341 x 4), localized delivery of antimicrobial agent (D4381 
x 6), take home drugs (D9630 x 2), surgical extractions (D7210 x 3), immediate partial upper denture (D5221), 
and fluoride varnish (D1206) provided from June 11, 2021, to September 30, 2021.
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 the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, 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 daily 
skilled services are not necessary. Our physician reviewer found based on the medical records provided there is 
no documentation that the enrollee requires the services on an inpatient basis, only in a skilled nursing facility 
setting. Services in the long-term care facility on a part time basis appear appropriate in this case. 
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic procedure (CPT code 97110) provided on
September 13, 2021.
You asked the Plan to pay for the therapeutic procedure. You say that the claim should be paid. The Plan
denied your request. The Plan says the service is not supported by the records.
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 97110 is therapeutic procedure, 1 or more areas, each 15
minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.
CPT code 97110 GP CQ KX (4 units) remains not supported. CPT code represents Therapeutic procedure, 1 or
more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and
flexibility, however the records indicate that the service is performed by a physical therapist assistant in a home
health or hospice setting. Of note, there is an appropriate Healthcare Common Procedure Coding System
(HCPCS) code (G0157) for the billed service. It is noted that multiple attempts were made to contact the
provider for additional information.
Based on this information, we decided that Medicare rules for coverage of the therapeutic procedure have not
been met. Therefore, we decided that the Plan does not have to pay for the therapeutic procedure (CPT code
97110) provided on September 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you under the Pick Your Perks program for an eye exam 
provided on September 21, 2021. 
 
You asked the Plan to reimburse you under the Pick Your Perks program for the eye exam. The Plan denied 
your request. The Plan says eye exams are not a covered benefit under the Pick Your Perks program. The Pick 
Your Perks program vision benefit covers reimbursement for vision hardware only. 
 
The Plan contract covers a supplemental Pick Your Perks reimbursement program benefit.  
 
We looked at the file and Medicare rules. The file shows that eye exams are not a covered benefit under the 
Pick Your Perks program. The Pick Your Perks program vision benefit covers reimbursement for vision 
hardware only. Therefore, we decided that the Plan does not have to reimburse you under the Pick Your Perks 
program for an eye exam provided on September 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 5, 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 providers must report services correctly. 
 
We looked at the file and Medicare rules. Review of the file shows the claim was billed with an inappropriate 
place of service 11. According to claims history, the specimen was obtained in an outpatient setting. Therefore, 
we decided that the Plan does not have to pay for the laboratory services provided on April 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on October 27, 
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 provider did not bill as required by Medicare coding regulations. 
 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 imaging services provided to the enrollee on October 27, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 home health skilled nursing visits. 
 
You asked the Plan to pre-approve 2 home health skilled nursing visits. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 2 home health skilled nursing visits. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the records do 
not show that skilled therapy services are required to effectively provide treatment, care, and/or services in 
order to improve your level of function, or to establish/perform a maintenance program to maintain your level 
of function and/or prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 2 home health skilled nursing visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 2 home health skilled nursing visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 heavy duty power wheelchair and accessories 
for the enrollee. 
 
You asked the Plan to pre-approve a Group 3 heavy duty power wheelchair and accessories. You say that the 
enrollee meets criteria for a Group 3 power wheelchair. The Plan denied your request. The Plan says that the 
member's weight is less than minimum for which a heavy duty wheelchair can be covered. 
 The Plan must follow Medicare rules. Medicare rules say that if a heavy duty, very heavy duty, or extra heavy 
duty PWC or POV is provided and if the beneficiarys weight is outside the range (i.e., for heavy duty  285  
450 pounds, for very heavy duty  428  600 pounds, for extra heavy duty  570 pounds or more), it will be 
denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. The file indicates the enrollee's weight is not within the range for a 
heavy duty wheelchair. Based on this information, we decided that Medicare rules for coverage of a Group 3 
heavy duty power wheelchair and accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Group 3 heavy duty power wheelchair and accessories for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (87486, 87496, 87498, 87541, 87581, 
87631, 87640, and 87798) provided on April 23, 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 providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service 
(POS) code per Medicare guidelines. The records show that the specimen was obtained in a nursing facility 
setting. Therefore, we decided that the Plan does not have to pay for the laboratory services (87486, 87496, 
87498, 87541, 87581, 87631, 87640, and 87798) provided on April 23, 2021.
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. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 documentation does not support that the enrollee requires at least 3 hours a day /5
day a week, or 15 hours over 7 consecutive days, of therapy services but there other indicators that this enrollee requires and can participate in a rehabilitation therapy program sufficient for this level of care, please provide particulars as to the indicators of intensity. 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: Favorable

We decided that the Plan has to reimburse you for the gym membership provided from April 28, 2021, through
November 4, 2021.
You asked the Plan to reimburse you for the gym membership. You say that you submitted the receipt in
April 2021. You say that you did everything in your power to submit the receipt with all the
information to the Plan, but you received the wrong reimbursement form from the Plan. You say that you
received a DME Reimbursement Form and not Wellness Reimbursement Form and it is not your
fault that this was delayed by the Plan. The Plan denied your request. The Plan says that the Plan requires a
legible receipt to be provided within 45 days. This receipt must show date of purchase, provider/recipient of
payment, amount of purchase, item purchased and form of payment. The timeframe to submit a legible receipt
begins the date of initial request. The receipt provided did not meet these requirements and appropriate
documentation was not received within the 45-day time frame.
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, the Plan has not provided us with the Plan's rules for
reimbursement for a gym membership (i.e., the section in the Evidence of Coverage for gym membership
reimbursement). Therefore, we decided that the Plan has to reimburse you for a gym membership provided
from April 28, 2021, through November 4, 2021.
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.