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

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from March 
2, 2020, through March 17, 2020, billed with code OGGC1. 
 You asked the Plan to pay for the SNF services as billed. You say that the evaluation by the facility's registered 
dietician clearly supports that the enrollee was at risk of malnutrition. Since risk of malnutrition does not have a 
specific diagnosis code, the physicians involved in care could not have documented this. The Plan denied your 
request. The Plan says the rules for reporting diagnoses for SNF payment first require that the diagnosis be 
support by a signed record from a physician or non-physician practitioner. 
 
The Plan must follow Medicare rules. Medicare rules say that The Plan must follow Medicare rules. Medicare 
rules say that payment for SNF services is based on a HIPPS code with five case-mix groups which are 
assigned based on the information from the MDS assessment. Section I of the MDS form requires that 
diagnoses reported be documented by a physician. 
 
We looked at the file and Medicare rules. In this case, we reviewed all documentation from physicians and 
non-physician practitioners and risk of malnutrition is not documented. This means that the rules for reporting 
this in Section I are not met. Therefore, we decided that the Plan does not have to pay for the skilled nursing 
facility (SNF) care provided from March 2, 2020, through March 17, 2020, billed with code OGGC1.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc. 
 
You asked the Plan to pre-approve Orthovisc. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee has not tried conservative therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Orthovisc. Our reviewer says that the 
requested use of Orthovisc is not medically necessary. Our physician reviewer found there has not been 
adequate time to determine that the corticosteroid injection and the non-pharmacologic treatment (physical 
therapy) have failed to improve the patient's symptoms. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orthovisc.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extra procedures to remove bone and disc. 
 
You asked the Plan to pre-approve extra procedures to remove bone and disc. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
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 extra procedures to remove bone and 
disc. Our reviewer says that the requested items/services are not considered medically reasonable and necessary 
in this case. Our physician reviewer found the imaging studies do not show severe lumbar stenosis. Surgery is 
not medically needed. 
 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of extra procedures to remove bone and disc have not been met. Therefore, we 
decided that the Plan does not have to pre-approve extra procedures to remove bone and disc.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (70450) provided on December 31, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, 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 services (70450) provided on December 31, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Kerecis Omega3 skin substitute. 
 
You asked the Plan to pre-approve the requested services. You say that this product assists in wound healing. 
The Plan denied your request. The Plan says that there is little evidence that this is an appropriate productive 
following Mohs surgery. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 requested skin substitute is necessary for post-surgery wound healing. 
 
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 been met. Therefore, we decided that the Plan has to 
pre-approve Kerecis Omega3 skin substitute.  
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 somewhat unstable and it is not clear if the enrollee is able 
to wean. The enrollee requires short-term additional acute care hospital services that can be safely completed at 
the current facility until more stable. There are no services at the LTACH that the enrollee requires that are not 
already available and covered at the current facility. Transfer to LTACH is not medically necessary as the 
enrollee is unstable and as it would not be clinically advantageous at this time. 
 
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical trays (CPT code A4550) provided on November 19, 2021. 
 
You asked the Plan to pay for the surgical trays. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is not covered 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. 
 
CPT code A4550 has a status code of 'B'. The rules say B: Payment for covered services are always bundled 
into payment for other services not specified. There will be no RVUs, or payment amounts for these codes and 
no separate payment is ever made.  Based on this information, we decided that Medicare rules for coverage of 
the surgical trays have not been met. Therefore, we decided that the Plan does not have to pay for surgical trays 
(CPT code A4550) provided on November 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), and a comprehensive oral 
evaluation (D0150), provided by a participating provider on May 11, 2021, to June 30, 2021. 
 
You asked the Plan to pay for a limited oral evaluation (D0140), and a comprehensive oral evaluation. You say 
that you had a root canal on May 11, 2021. You say that you had to go back because you were still 
experiencing pain with the same tooth. The Plan denied your request. The Plan says D0140 is not a covered 
benefit. The Plan says that the benefit limit for D0150 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 Plan's coverage rules apply in this case. The Plan covers a 
comprehensive oral evaluation (D0150) once every 6 months. A limited oral evaluation (D0140) is not a 
covered benefit.  
We looked at the file and Medicare rules. Evidence was provided to show that D0150 was provided on May 11, 
2021. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral 
evaluation (D0150) have already been met. A limited oral evaluation (D0140) is not a covered benefit.  
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), and a 
comprehensive oral evaluation (D0150), provided by a participating provider on May 11, 2021, to June 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions, erupted tooth requiring removal of bone 
and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided 
November 15, 2021. 
 
You asked the Plan to pay for the extractions. You say that this was an emergency extraction. The Plan denied 
your request. The Plan says this service is not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the extractions, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided November 15, 2021.
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 the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 improving and should only require short-term additional 
acute care hospital services that can be safely completed at the current facility until appropriate for a lower 
level of care. There are no services at the LTACH that the enrollee requires that are not already available and 
covered at the current facility. Transfer to LTACH is not medically necessary as it would not be clinically 
advantageous at this time. 
 
 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910), and intraoral imaging 
(D0210) provided by an out-of-network provider March 30, 2021, to September 20, 2021. 
 
You asked the Plan to pay for periodontal maintenance (D4910), and intraoral imaging. You say that you have 
already paid this bill. You say that you would like to be reimbursed. 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 
periodontal maintenance (D4910), and intraoral imaging (D0210) provided by an out-of-network provider on 
March 30, 2021, to September 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve durable medical equipment to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that getting the supplies at a retail store creates a 
high chance of contracting an infection. The Plan denied your request. The Plan says the supplies within the kit 
are available without the kit. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
durable medical equipment 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 the surgical extraction (D7210) provided on December 20, 2021. 
 
You asked the Plan to pay for the surgical extraction. You say that you found in the Plan documentation that 
tooth extractions are a covered benefit. You also say that you need this claim to be reviewed and the cost of 
$304.00 to be reimbursed to you. The Plan denied your request. The Plan says this service is not covered under 
your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, surgical extractions are not among 
those covered under this benefit. The only type of extractions that are covered under your benefit are non-
surgical extractions. Therefore, we decided that the Plan does not have to pay for the surgical extraction 
(D7210) provided on December 20, 2021.
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 the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 you appears to be improving and should only require short-term additional acute care 
hospital services that can be safely completed at the current facility until appropriate for a lower level of care. 
There are no services at the LTACH that you require that are not already available and covered at the current 
facility. Transfer to LTACH is not medically necessary as it would not be clinically advantageous at this time. 
 
 
 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from April 25, 2022, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from April 25, 2022, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary. 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from April 
25, 2022, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental health 
treatment beyond the date in question of April 25, 2022, forward. Our physician reviewer found you did not 
require inpatient mental health treatment beyond April 25, 2022, as you were not a danger to yourself or others 
and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was 
taking place beyond the date in question. It did not appear that the services for the dates in question were 
reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from April 25, 2022, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from April 25, 2022, forward.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hot or cold packs therapy (97010) provided on December 17, 2021. 
 
You asked the Plan to pay for hot or cold packs therapy. You say that these services were authorized and are 
supported in the record. The Plan denied your request. The Plan says payment for this service is always 
included in the payment for another service. 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
We find that CPT code 97010 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 97010 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of hot or cold packs therapy have not been met. Therefore, we decided that the Plan does not have to pay for 
hot or cold packs therapy (97010) provided on December 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiac risk assessment genetic screening testing (CPT 
code(s): 81404 and 81479) provided on July 29, 2021. 
 
You asked the Plan to pay for the screening testing. You say that the claim should be paid. The Plan denied 
your request. The Plan says the Medicare rules have not been met. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the screening testing, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for the cardiac risk assessment genetic screening testing (CPT code(s): 81404 and 81479) provided on July 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431) and localized 
delivery of antimicrobial agents (D4381) provided on January 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were dissatisfied with the care you received 
and are frustrated that your provider did not check your benefits before providing services. The Plan denied 
your request. The Plan says these services are 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
adjunctive pre-diagnostic test (D0431) and localized delivery of antimicrobial agents (D4381) provided on 
January 19, 2022.  
Your complaint about the treatment received from a Plan-contracted is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.