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

 
We decided that the Plan does not have to pre-approve a positioning seat for persons with special orthopedic 
needs (T5001) and an incontinence cover (E1399). 
 
You asked the Plan to pre-approve an adaptive car seat with an incontinence cover. You say that the enrollee is 
currently using a typical seat in a car with shoulder strap. This is not appropriate as she is pushing the seat belt 
away from herself and is getting out leading to safety issues. She would not tolerate a harness system (like the 
EZ vest) as she has sensory concerns to wearing seat belts used as restraint. The Plan denied your request. The 
Plan says an adaptive car seat with incontinence cover is not medical in nature and not reasonable or medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a positioning seat for persons with special orthopedic needs 
(T5001) and an incontinence cover (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete rebased mandibular denture (D5711) provided by 
a participating provider on September 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not informed that you would be 
charged for this. 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 on date of service September 14, 2022. A 
complete rebased maxillary denture was provided the same. Therefore, we decided that the Plan does not have 
to pay for a complete rebased mandibular denture (D5711) provided by a participating provider on September 
14, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee has had multiple hospitalizations. The 
Plan denied your request. The Plan says the Medicare criteria for SNF admission were not met and the 
enrollee's needs can be met at a lower level of care. 
 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 that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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 SNF care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 72125, 96372, 93005, A4556, A4209, and 
A4208 billed for date of service July 17, 2022. 
 
You asked the Plan to pay for procedure code(s) 72125, 96372, 93005, A4556, A4209, and A4208. 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. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. The records indicate that procedure code 72125 was provided to the enrollee 
while an inpatient or outpatient. Per the Physician Fee Schedule, there is a Professional/Technical indicator of 1 
for CPT code(s) 72125. This means there is both a professional and technical component for the CPT code(s). 
In this case, an appropriate modifier to indicate the professional component has not been billed with CPT 
code(s) 72125. Based on this information, we decided that Medicare rules for coverage of procedure code 
72125 have not been met.  
 
In this case, the enrollee received services (96372) while in an outpatient hospital setting. Per Medicare 
payment guidelines, code 96372 has a PC/TC indicator of 5 and payment may not be made for this code when 
provided to patients in an outpatient hospital setting. 
 The review also shows that the medical records provided represent professional charges; however, procedure 
code 93005 was provided in a facility with a place of service code of 23. Procedure code 93005 has a PC/TC 
Modifier Status of 3, which specifies a Technical Component only code. 
 
We also find that code A4556 has a status code of "P" under the Medicare Physicians Fee Schedule Database 
(MPFSDB) and no separate payment is made for this code under the fee schedule as payment is bundled into 
the payment for the services to which this code is incident to. 
 
We also find that procedure codes A4208 and A4209 have a Status Indicator of X on the Physician Fee 
Schedule. This means that procedure codes A4208 and A4209 are statutorily excluded from payment. 
 
Therefore, we decided that the Plan does not have to pay for procedure code(s) 72125, 96372, 93005, A4556, 
A4209, and A4208 billed for date of service July 17, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 1, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the records support multiple procedures on 
this date of service. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service September 1, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 8, 
2022. 
 
You asked the Plan to pay for procedure code 76641. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service September 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, and the enrollee's needs can be met at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that while rehabilitation consists of pain management and mobilization as tolerated 
the enrollee does not require intensive or complex rehabilitation services for an uncomplicated vertebral 
compression fracture.  
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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this transfer and admission to a LTACH 
is medically necessary. The Plan denied your request. The Plan says a transfer is not medically necessary. 
 
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 transfer to the LTACH is not medically necessary at this time as the enrollee is not 
yet stable and as it would not be clinically advantageous. Completion of treatment at the current facility is 
recommended.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extension of the 100-day skilled nursing benefit. 
 
You asked the Plan to pre-approve an extension of the 100-day skilled nursing benefit. You say that you would 
like the Plan to cover a continued SNF stay. The Plan denied your request. The Plan says Skilled Nursing 
Facility (SNF) care beyond 100 days per benefit period is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from July 25, 2022, to 
November 2, 2022. The Plan has covered 100 days of SNF care. 
 
 
 Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve an extension of the 100-day skilled nursing benefit.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy (97124), and manual therapy 
techniques (97140) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve massage therapy (97124), and manual therapy techniques (97140). You say 
that you are entitled to have the massage therapy if it is medically necessary as directed by your primary care 
physician (PCP). The Plan denied your request. The Plan says this request for out-of-network services can be 
provided in-network. 
 
  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 
massage therapy (97124), and manual therapy techniques (97140) to be provided by an out-of-network (OON) 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam CT capture (D0364), pulp vitality tests 
(D0460), and an internal root repair (D3333) provided by a participating provider on August 1, 2022. 
 
You asked the Plan to pay for a cone beam CT capture, pulp vitality tests, and an internal root repair. You say 
that you would like the Plan to pay for this. The Plan denied your request. The Plan says the rendered dental 
services are not covered benefits. 
 
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 pay for a cone 
beam CT capture (D0364), pulp vitality tests (D0460), and an internal root repair (D3333) provided by a 
participating provider on August 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the preventive procedure (D1999), problem focused limited 
oral evaluation (D0140), and maxillary partial denture (D5213) provided on August 10, 2022, by an out-of-
network (OON) provider. 
 
  You asked the Plan to pay for the preventive procedure, problem focused limited oral evaluation, and maxillary 
partial denture. You say that you received partial dentures in February of 2019, and they broke. The Plan 
denied your request. The Plan says the preventive procedure is not a covered benefit, and you are responsible 
for the remaining balance for the problem focused limited oral evaluation. The Plan also says that the maxillary 
partial denture exceeds the maximum allowed per period. 
 
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 preventive procedure (D1999) is 
not among those covered under this benefit. The contract says that the Plan only offers benefits for dental 
services rendered by an in-network provider. The record shows that the Plan paid the allowed amount of $33 
for the problem focused limited oral evaluation (D0140) that was rendered by an OON provider, and you are 
responsible for the difference between the billed amount and allowed amount. The contract also says that 
maxillary partial denture (D5213) is limited to one procedure every five plan years. The record shows that you 
received a maxillary partial denture (D5213) on February 21, 2019, and your maxillary partial denture (D5213) 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the preventive 
procedure (D1999), problem focused limited oral evaluation (D0140), and maxillary partial denture (D5213) 
provided on August 10, 2022, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services provided July 5, 
2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you disagree with the 
copayment. 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 $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for emergency room services. This item/service falls within the 
emergency 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 emergency room services 
provided July 5, 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 IRF care is the most appropriate setting for the 
enrollee to continue treatment and return to her baseline. The enrollee is medically stable and motivated to 
complete physical therapy. The Plan denied your request. The Plan says the IRF care is medically necessary, 
and the enrollee's needs can be met at a lower level of care such as a skilled nursing facility. 
 
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 enrollee was admitted for peripheral vascular disease and had an above the knee 
amputation. The enrollee's medical problems are stable, and there are no complex nursing or rehabilitation 
needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve personal care assistance services. 
 
You asked the Plan to pre-approve personal care assistance services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
We looked at the file and Medicare rules. The requested services are for personal care assistance. These 
services are not considered skilled therapy or skilled nursing services. Based on this information, we decided 
that Medicare rules for coverage of personal care assistance services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve personal care assistance services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 2 hours a day, 7 days a week of home 
health aide services. 
 
You asked the Plan to pre-approve the aide services. You say that the enrollee's medical condition has 
deteriorated since the last referral. The Plan denied your request. The Plan says the additional 2 hours a day, 7 
days a week are considered custodial care and personal care. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
  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 aide services. Our reviewer says 
that the services are not medically reasonable and necessary. Our physician reviewer found that the enrollee 
does not require 5 hours a day of personal care. 3 hours per day to attend to their care needs is sufficient. The 
additional 2 hours per day are not necessary and consistent with custodial care as they are more than necessary 
to meet their personal care needs. 
 
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 aide services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an additional 2 hours a day, 7 days a week of home health aide services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walk-in shower. 
 
You asked the Plan to pre-approve a walk-in shower. You say that this is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says this equipment is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a walk-in shower.