Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 hours a day, 7 days a week of home health aide 
services. 
 
You asked the Plan to pre-approve home health aide services. You say that you need additional hours of home 
health aide care. The Plan denied your request. The Plan says there is no medical need for home health aide 
services beyond what has already been approved. 
 
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 home health aide services. Our 
reviewer says that this additional home health aide care is not medically necessary. Our physician reviewer 
found that the enrollee does not have documented skilled nursing needs. The enrollee does not have 
documented skilled therapy needs. There is no evidence that HHA services are required to assist in the 
treatment of illness or injury. As such, the requested HHA services are not medically necessary, reasonable or 
coverable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health aide services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 4 hours a day, 7 days a week of home health aide services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the podiatry visit provided on May 04, 
2022. 
 
You asked the Plan to waive the copayment for the podiatry visit. You say that you only went for a toenail cut 
and it should be free. 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 $45 
copayment for podiatry services. 
 
You have been asked to pay a $45 copayment for the podiatry visit. This item/service falls within the podiatry 
services benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan.  Therefore, we decided that the Plan does not have to waive the copayment for the podiatry visit provided 
on May 04, 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 the enrollee is medically stable to be 
transferred to LTACH. You say that the enrollee exceeds the capabilities of all lower levels of care in the 
geographical area as the enrollee requires mechanical ventilation via tracheostomy and hemodialysis. The Plan 
denied your request. The Plan says LTACH is not medically necessary. The enrollee has not finished their full 
course of care in the hospital. The enrollee can safely receive the service they need in current hospital setting. 
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where the enrollee is currently receiving care. The health plan has approved ongoing care in the 
current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 14, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service 
on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on January 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for deep sedation/general anesthesia first 15 minutes (D9222) 
and therapeutic parenteral drug, single administration (D9610) provided on May 4, 2022. 
 
You asked the Plan to pay for dental services. You say that you did not realize the requested services were not 
covered benefits. The Plan denied your request. The Plan says this service is 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. Deep sedation/general 
anesthesia first 15 minutes (D9222) and therapeutic parenteral drug, single administration (D9610) are not 
covered under the Plans dental benefits. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested deep sedation/general 
anesthesia first 15 minutes (D9222) and therapeutic parenteral drug, single administration (D9610) are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for deep 
sedation/general anesthesia first 15 minutes (D9222) and therapeutic parenteral drug, single administration 
(D9610) provided on May 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Receiver (monitor), dedicated, for use with therapeutic 
glucose continuous monitor system (K0554) supply allowance used with a therapeutic CGM device (K0553). 
 
You asked the Plan to pre-approve the CGM and supplies. You say that you would appreciate the assistance in 
approval for a continuous glucose monitoring equipment to aid the enrollee in their healthcare. The Plan denied 
your request. The Plan says the enrollee does not meet the Medicare criteria. 
 
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 the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the CGM and supplies have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Receiver (monitor), dedicated, for use with 
therapeutic glucose continuous monitor system (K0554) supply allowance used with a therapeutic CGM device 
(K0553).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an angiography (75726) provided on March 26, 2022. 
 
You asked the Plan to pay for the angiography. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the code billed is not separately payable. 
 
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 CPT code 75726 is not supported in the medical record. Specifically, the code was not billed with 
an appropriate modifier to support a separate service from the embolization procedure performed. Based on this 
information, we decided that Medicare rules for coverage of the angiography have not been met. Therefore, we 
decided that the Plan does not have to pay for an angiography (75726) provided on March 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), oral cleaning (D1110), 
bitewing x-rays (D0274), and a take-home mouth rinse (D9630) provided on July 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like a one-time exception for 
coverage of these services due to your confusion regarding mandatory and optional supplemental benefits. The 
Plan denied your request. The Plan says the dental services were received from an out-of-network provider and 
are not covered by your supplemental 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. 
 
 
 
 
 
 The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a periodic oral evaluation (D0120), oral cleaning (D1110), bitewing x-rays (D0274), and a take-
home mouth rinse (D9630) provided on July 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to request reconsideration 
of the denied claim. The Plan denied your request. The Plan says dental services from an out-of-network 
provider are not covered by your supplemental 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. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve the dental 
services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-precision abutment (D6191) 
 
You asked the Plan to pre-approve the semi-precision abutment. You say that the services should be covered as 
you disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they 
do not fall within your dental 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 pre-approve a 
semi-precision abutment (D6191)
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service  
February 11, 2022. 
 
You asked the Plan to pay for procedure code 71045. The Plan denied your request. The Plan says this 
procedure to procedure (PTP) edit has a modifier indicator of 1, which indicates modifiers associated with 
NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 We find that procedure code 71045 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 71045 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 71045 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 71045 billed for date of service February 11, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic services (97110) provided on February 11, 2020. You asked the Plan to pay for therapeutic services. You say that these services were medically necessary and 
were billed correctly. The Plan denied your request. The Plan says these services are not supported as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that these services are not supported in the medical record. Specifically, the documentation shows that 
this claim was billed by a Nurse Practitioner but the therapy services at issue were rendered by a Physical 
Therapy Assistant. There is no indication that the Nurse Practitioner was present on site while the therapy 
services were being rendered. The incident-to requirements have not been met in this case. Based on this 
information, we decided that Medicare rules for coverage of therapeutic services have not been met. Therefore, 
we decided that the Plan does not have to pay for therapeutic services (97110) provided on February 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (POV), scooter (K0800). 
 
You asked the Plan to pre-approve a scooter. You say that you have bone disease, a slipped disc and cannot 
walk far with a walker. The Plan denied your request. The Plan says the POV is being denied because your 
medical needs can be met by using a rollator, transport wheelchair, and proper fitting footwear. We do not have 
evidence that you can safely use the POV. A POV can only be approved if the enrollee is able to safely use it. It 
can only be approved if it is medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a scooter. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found according to Medicare, a power mobility 
device is medically necessary if you have a mobility limitation that significantly impairs your ability to 
participate in one or more mobility-related activities of daily living. The mobility limitation cannot be 
sufficiently and safely resolved by the use of a fitted cane or walker, or you do not have sufficient upper 
extremity function to self-propel an optimally configured manual wheelchair.  Additionally, if any POV or 
PWC is only for use outside the home, it is denied as noncovered. You must also have the mental and physical 
capabilities to safely operate the power wheelchair and the home provides adequate access between rooms, 
maneuvering space, and surfaces for the operation of the PWC. 
In this case, the documentation doesn't support that you require the use of a POV in the home for MRADLs or 
that you can safely operate a POV in the home. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a scooter have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a power operated vehicle (POV), scooter (K0800).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on July 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that your crown fell off and you had to get it fixed. 
The Plan denied your request. The Plan says the dental services were received from an out-of-network provider 
and are not covered by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided on July 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Euflexxa. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has bilateral knee pain related to osteoarthritis. The enrollee has failed conservative 
treatment. The documentation does not support that the enrollee has tried and failed Orthovisc and Synvisc or 
Synvisc One. The documentation does not support that Orthovisc and Synvisc or Synvisc One would likely be 
less effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does not meet criteria 
for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 2, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services are not 
payable. 
 
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 payment for the billed CPT codes is not supported in the medical record. Specifically, the billed 
codes are assigned a PC/TC indicator of 1. As such, when billed with a facility place of service, the 
professional interpretation must be billed with modifier -26 for payment to be considered. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for the lab services provided on February 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (G0483) provided on July 15, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you have provided records to support the 
service billed. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
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. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for laboratory services (G0483) provided on July 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says further 
imaging is needed. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered under 
certain medical indications. 
 
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 requested services. Our physician 
reviewer found that the enrollee has chronic low back pain due to spondylosis. The enrollee has radiculopathy. 
The review has determined that the requested treatment is not indicated for the enrollee's condition. Therefore, 
the procedure is 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.