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

 
We decided that the Plan does not have to pre-approve an interim complete upper denture (D5810). 
 
You asked the Plan to pre-approve an interim denture. You say that you need this denture, but the cost is too 
high. The Plan denied your request. The Plan says this service is not covered by your dental benefit. 
 
  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 an 
interim complete upper denture (D5810).
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 complexity of your nursing, medical and rehabilitation needs do not require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, at an 
intensive rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation facility. Therapy services may be provided at a lower 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says care can be provided in the current inpatient hospital. 
 
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 appears to be still dependent on mechanical ventilation and it is not clear 
if he is able to wean. He requires short-term additional acute care hospital services that can safely completed at 
the current facility. The enrollee does not require services at the LTACH that are not already available at the 
current facility. Transfer to LTACH is not medically necessary as it would not be clinically advantageous. 
Transfer to a lower level of care may be considered when treatment has completed. 
 
  
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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first 
intraoral periapical x-ray (D0220), repair resin mandibular partial denture base (D5611), and surgical extraction 
(D7210) provided on October 4, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, repair 
resin mandibular partial denture base, and surgical extraction. You say that the provider called the day of the 
services and were told these services would be covered. The Plan denied your request. The Plan says these 
services are not covered under your benefit 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. 
 
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 
problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), repair resin 
mandibular partial denture base (D5611), and surgical extraction (D7210) provided on October 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair (E0240). 
 
You asked the Plan to pre-approve a shower chair. You say that the requested item is a medical necessity for 
the enrollee. 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 (E0240).
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 requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 records do not document the need for 
intravenous medications, new tube feeding, or ostomy care or daily complex wound care. You are walking 
household distances with minimum assistance and is minimum assist for transfers. You do not require the 
services on an inpatient basis, only in a skilled nursing facility setting. Services in a 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
December 10, 2020, to December 11, 2020. 
 
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 DRG was updated.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 291 (HEART FAILURE AND SHOCK 
WITH MCC). 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 services. Our reviewer 
says that the services at issue in this case were not supported by the medical records. Our physician reviewer 
found while the enrollee initially was given low flow nasal cannula therapy, the enrollee's physical 
examinations by the provider did not support acute respiratory distress or increased work of breathing to be 
present, and Lasix was administered for the congestive heart failure exacerbation. The enrollee was 
documented toimprove "rapidly", and this was supported in physical assessments and the patient was on room 
air and discharging home by day one. The more appropriate DRG would be DRG 293 (HEART FAILURE 
AND SHOCK WITHOUT CC/MC).  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from December 10, 2020, to December 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0554). 
 
You asked the Plan to pre-approve a continuous glucose monitor. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for CGMs and 
related supplies have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor (K0554).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Cala Trio device for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of the Cala trio device in the 
setting of essential tremor have not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. There is a need for 
further study to be done on the requested device. The published literature on the requested device/item is 
largely from an open label proof of concept study. Such an experimental design only yields preliminary results 
which would necessitate further evaluation in more methodologically sound studies. Given the need for further 
study and validation of prior findings, the requested item would be better classified as being experimental at 
this time as such it would not be eligible for coverage. Our physician reviewer found that the enrollee's 
condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Cala Trio device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease. In addition, the requested orthopedic shoes are 
not an integral part of a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the 
Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to 
pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy (CPT code 90832) provided on November 
30, 2021, by an out-of-network provider, Emily Crowder. 
 
You asked the Plan to pay for the psychotherapy. You say that you do not understand why the services are not 
being covered. The Plan denied your request. The Plan says this provider is a mental health counselor and not 
eligible to enroll in Medicare. 
 The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the psychotherapy have not been met. This service is not covered 
as the provider is a mental health counselor and not eligible for payment by the health plan or original 
Medicare. Therefore, we decided that the Plan does not have to pay for the psychotherapy (CPT code 90832) 
provided on November 30, 2021, by an out-of-network provider, Emily Crowder.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from October 12, 2017, to October 31, 2017. 
 
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 payment integrity post-service, post-payment Resource Utilization Group (RUG) clinical 
validation audit found that the provider has reported skilled services with the incorrect RUG Health Insurance 
Prospective Payment System (HIPPS) score. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
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 the provider billed these services 
using a rehab RUG score of "Rehab Very High" for October 13, 2017 to October 19, 2017. This classification 
requires ALL of the following: 
 
1. Total skilled therapy treatment minutes of at least 500 minutes across all disciplines provided during 
lookback 
2. At least 1 therapy discipline treating the member at least 5 distinct calendar days during lookback, 
3. At least an ADL score of 6-10 
 
The enrollee did not meet all three of these requirements for the therapy received during the dates at issue in 
this case. Additionally, the provider billed these services using a rehab RUG score of "Rehab High" for 
October 18, 2017 to October 24, 2017. This classification requires ALL of the following: 
1. Total skilled therapy treatment minutes of at least 325 minutes across all disciplines provided during 
lookback, 
2. At least 1 therapy discipline treating the member at least 5 distinct calendar days during lookback, 
3. At least an ADL score of 6-10 
 
The enrollee did not meet all of these requirements for the therapy received during the dates at issue in this 
case. 
 
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 skilled nursing facility (SNF) services provided to the enrollee from October 12, 2017, to 
October 31, 2017.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on May 11, 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 denied procedure is considered inclusive to another procedure. 
 
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 27507 is a column II code to column I code 27299. 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 surgical services provided to the enrollee on May 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain 
(70450) provided on October 23, 2021. 
 
You asked the Plan to pay for the CT scan services. You say that you would like this claim reprocessed based 
on the medical documentation. The Plan denied your request. The Plan says this claim has not been billed 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 the computed tomography (CT) scan of the head or brain (70450) 
provided on October 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the portable whirlpool jacuzzi (E1399). 
 
You asked the Plan to pre-approve the jacuzzi. You say that the medical records provided will show proof of 
medical necessity. The Plan denied your request. The Plan says this item is not medically necessary because 
this item could be used in the absence of illness or injury. 
 
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 the portable whirlpool jacuzzi (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit services provided on January 15, 2021. 
 
You asked the Plan to pay for the office visit services. You say that the charge is for the facility component of 
the clinic visit. You say that the charge should be reprocessed for payment. The Plan denied your request. The 
Plan says the professional component must be billed on CMS 1500 form. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that the required format for 
submitting professional and supplier claims to Medicare on paper is the CMS-1500 claim form.  We find that the services are not supported in the medical record. Specifically, this is an outpatient claim and 
the billed codes are not recognized under the outpatient prospective payment system. Based on this 
information, we decided that Medicare rules for coverage of the office visit services have not been met. 
Therefore, we decided that the Plan does not have to pay for the office visit services provided on January 15, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-covered swift microwave therapy (CPT code A9270) 
provided on November 10, 2021. 
 
You asked the Plan to pay for the non-covered service. You say that you were reimbursed for the first 
procedure in October. You state the wrong code was used on this second procedure. You state you spoke with 
someone at the health plan, and they said it should be covered since the first procedure was covered. The Plan 
denied your request. The Plan says you were given a notice when you submitted the appeal that notifies you 
that swift microwave therapy is not covered by insurance. 
 
   
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. Documentation for services rendered on November 10, 2021, 
supports swift microwave therapy is not covered by insurance. Plan incorrectly paid for other dates-of-service, 
and will honor our error, but will not continue paying for a treatment that is a non-covered service. Based on 
this information, we decided that Medicare rules for coverage of the non-covered service have not been met. 
Therefore, we decided that the Plan does not have to pay for non-covered swift microwave therapy (CPT code 
A9270) provided on November 10, 2021.