Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) and a core build-up (D2950) provided 
by a participating provider. 
 
You asked the Plan to pre-approve a crown and a core build-up. You say that these services are medically 
necessary. The Plan denied your request. The Plan says the medical criteria for the requested services have not 
been met. 
 
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 Plan covers a crown and a 
core build-up when the services are medically necessary and reasonable.  
 
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 crown and a core build-up. Our 
physician reviewer found there has been no completed endodontic treatment the Plan would not find that 
criteria have been met for the requested procedures. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a crown and a core build-up have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) and a core build-up (D2950) provided by a participating 
provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 25, 2022, to 
April 23, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from March 25, 2022, to April 
23, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided June 2, 2022, to June 4, 2022.

You asked the Plan to pay for acute inpatient hospital care. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says that the services rendered were not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee presented to the emergency department on June 2, 2022 with sudden onset blurry vision described a vision loss. On evaluation the enrollee had a normal neurologic exam. Concern for possible transient ischaemic attack (TIA) versus possible cardiac etiology with near syncope and vision loss. Low suspicion for large vessel occlusion given normal exam. Computerized tomography (CT) brain negative. Doubt hemorrhage. No head trauma. The enrollee denied chest pain or shortness of breath, electrocardiogram (EKG) unremarkable as well, low suspicion for arrhythmia, pulmonary embolism. The enrollee was admitted for magnetic resonance imaging (MRI), further work-up and additional management. Troponin negative. The enrollee's condition stabilized and improved and the enrollee was discharged home when considered medically stable on June 4, 2022. The documentation shows that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided June 2, 2022, to June 4, 2022. 

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.
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 you are currently in the hospital with a ruptured 
appendix. Your doctors and surgery team recommend IRF until surgery is safe and the infection can be cleared. 
You currently have a drainage tube that needs full-time monitoring and antibiotics. The Plan denied your 
request. The Plan says the request is not medically necessary, the services you need can be provided safely in 
other settings, for example, 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 your medical problems are stable and there are no complex nursing or rehabilitation 
needs. There is no documented need for intensive rehabilitation services and medically necessary care can be 
provided in a different level of care. 
 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36010, 77001, and 75827, billed for date of 
service June 22, 2022. 
 
You asked the Plan to pay for procedure codes 36010, 77001, and 75827. The Plan denied your request. The 
Plan says payment for codes 36010, 77001, and 75827, is bundled into payment for code 36561.  
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 36010 
is a column II code to column I code 36561. We have also confirmed that codes 77001 and 75827 are column 
II codes to column I code 37238. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 36010, 77001, and 75827, billed 
for date of service June 22, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit coded 99285 provided on 
July 11, 2022. 
 
You asked the Plan to pay for the emergency department visit. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99285 is not supported in the medical record. Specifically, this code was billed with 
diagnosis codes I73.9 (Peripheral vascular disease, unspecified) and I70.219 (atherosclerosis of native arteries 
of extremities with intermittent claudication, unspecified extremity). These diagnosis codes should not be billed 
together. This means that this code is not payable as billed. Based on this information, we decided that 
Medicare rules for coverage of the emergency department visit have not been met. Therefore, we decided that 
the Plan does not have to pay for the emergency department visit coded 99285 provided on July 11, 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 you need to get this rehab started right away and you 
need to get up and moving again. Your quality of life is not getting better by staying the hospital and you want 
to get up and moving again to be able to do things on your own. The Plan denied your request. The Plan says 
criteria for admission to the Acute Inpatient Rehabilitation setting have not been met. Your ongoing skilled 
therapy and nursing needs can be provided at a lower level of care such as at 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 your medical problems are stable and there are no complex nursing or rehabilitation 
needs. There is no documented need for intensive rehabilitation services and medically necessary care can be 
provided in a different level of care. 
 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chest x-ray provided on April 24, 2022. 
 
You asked the Plan to pay for the chest x-ray. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that the Plan has made outreach to the primary insurance carrier for the 
explanation of benefits (EOB); however the EOB has not been received. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has tried to 
obtain the EOB from the primary insurance carrier and the EOB has not been received. As the secondary 
insurer, the Plan cannot be held responsible for the chest x-ray until the primary insurer has denied the claim 
for these services. Therefore, we decided that the Plan does not have to pay for a chest x-ray provided on 
April 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 82310, 82728, 83540, 
83550, 83970, 84100) provided on July 6, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. The documentation submitted 
showed that the laboratory tests reported were related to treatment of ESRD since end-stage renal disease was 
indicated as a reason for the laboratory tests and a separate professional visit unrelated to ESRD was not 
indicated in the medical record. Therefore, the laboratory tests are included in the dialysis services. Based on 
this information, we decided that Medicare rules for coverage of the laboratory services have not been met. 
Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 82310, 
82728, 83540, 83550, 83970, 84100) provided on July 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Hi Handle wheel walker and a brake seat metal basket. 
 
You asked the Plan to pre-approve a wheel walker. You say that your walker does not work anymore, and the 
wheel pops out because there is a nail that comes out. Your family has tried to fix it. You would benefit from 
the requested walker because the handle is higher and would help with body position. The Plan denied your 
request. The Plan says you had a face-to-face exam done at your home. You were able to walk using your basic 
walker. Your doctor did not provide reasons as to why you need this type of walker. At this time, you do not 
have a medical need for this type of walker. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The records show that you do not meet criteria for coverage of the 
requested walker. Based on this information, we decided that Medicare rules for coverage of a wheel walker 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a Hi Handle wheel walker 
and a brake seat metal basket.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cerebral perfusion analysis using computed tomography 
(CT) provided on May 13, 2022. 
 
You asked the Plan to pay for the cerebral perfusion analysis using CT. You say that you are appealing the 
denied services. The Plan denied your request. The Plan says the service at issue is experimental and therefore 
not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that medically necessary services are those that are 
reasonable and necessary for the diagnosis or treatment of an illness or injury. Medically necessary services 
include services to improve the functioning of a malformed body member. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the cerebral perfusion analysis using CT. 
Our reviewer says that the cerebral perfusion analysis using CT is not medically necessary. Our physician 
reviewer found that the CT perfusion study did not adhere to the CMS rules for CT Perfusion. These rules 
require large vessel occlusion in the brain to assess the utility of possible intervention. Review of the reports of 
the computed tomography angiography of the head showed no such large vessel occlusion. 
 
  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 cerebral perfusion analysis using CT have not been met. Therefore, we 
decided that the Plan does not have to pay for a cerebral perfusion analysis using computed tomography (CT) 
provided on May 13, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 8, 2022, to 
May 5, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you would like this claim 
reprocessed based on the medical records. The Plan denied your request. The Plan says the claim has not been 
billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from April 8, 2022, to May 5, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical services to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the services are necessary. The 
Plan denied your request. The Plan says there is an in-network provider that can perform the services you need. 
 
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 the surgical 
services to be provided by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for May 31, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for May 31, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozempic injection. 
 
You asked the Plan to pre-approve Ozempic. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested drug is considered self-administered. The 
Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also 
says the requested drug is not covered under Medicare 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 Ozempic injection.  
 Benefits for Ozempic 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for date of service June 20, 
2022. 
 
You asked the Plan to pay for procedure code 99233. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 99233 is bundled into payment for code 99222. 
 
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 99233 
is a column II code to column I code 99222. 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 procedure code 99233 billed for date of service June 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service July 18, 
2022. 
 
You asked the Plan to pay for procedure code 99497. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 99497 is bundled into payment for code 99223.  
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 99497 
is a column II code to column I code 99223. 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 procedure code 99497 billed for date of service July 18, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Revlimid capsule. 
 
You asked the Plan to pre-approve Revlimid. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested drug is considered self-administered. The 
Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also 
says the requested drug is not covered under Medicare 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 Revlimid capsule.  
 Benefits for Revlimid may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.