Persius/hicric huggingface dataset:
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 enrollee is stable and suitable for 
transfer to an LTACH. The Plan denied your request. The Plan says based on Medicare guidelines, the 
requested LTACH services do not meet the requirements for approval. 
 
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 that the enrollee appears to be somewhat unstable requiring short-term additional 
acute care hospital services that can be safely administered at the current facility until more stable and 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility. Transfer to the LTACH is not medically necessary as the enrollee is not yet 
stable for transfer and as it would not be clinically advantageous. Completion of treatment at the current facility 
is recommended. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on April 21, 2022, by an OON 
provider. 
 
You asked the Plan to pay for wound care supplies. You say that these supplies are a separate billable expense 
and have not been included in any other billing to treat the wounds. You also say that the provider supplied the 
medically necessary surgical dressings for the treatment of the enrollee's wounds  The Plan denied your 
request. The Plan says the out-of-network services were not authorized. 
 
 
 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for wound care supplies provided on April 21, 2022, 
by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services, diagnostic services, an angioplasty, and 
surgical services provided on April 15, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services, diagnostic services, an angioplasty, and surgical services. 
You say that this provider provided services because it was medically necessary and there was not an in-
network facility for the patient that could assist. You also say that the member was seen by an in-network 
provider with the Plan on April 15, 2022, and he is the one who ordered this procedure. The Plan denied your 
request. The Plan says this provider is not a network provider with the Plan. The Plan also says they have also 
determined that these services are not urgent or emergent, nor were they approved in advance. 
 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for laboratory services, diagnostic services, an 
angioplasty, and surgical services provided on April 15, 2022, 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 pin retention (D2951) provided on April 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that the tooth could only be filled securely using a 
reinserted pin. The Plan denied your request. The Plan says the services you received are not covered under 
your supplemental 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 pay for the pin 
retention (D2951) provided on April 26, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that the enrollee was due for a 6 month 
follow up in July of 2022. The Plan denied your request. The Plan says these screenings are performed on an 
annual basis. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
 
 
 We reviewed the file and the Medicare rules. We find that the enrollee last received an LDCT on January 12, 
2022, and this benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a 
low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray services coded 71045 provided on March 16, 2022. 
 
You asked the Plan to pay for the x-ray services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services were billed incorrectly. 
 
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 71045 is not supported in the medical record. Specifically, this code was billed with 
place of service 22, outpatient hospital, however, the documentation supports that this service was performed in 
an inpatient setting with the admission date of January 15, 2022 and a discharge date of March 23, 2022. This 
means this code is not payable as billed. Based on this information, we decided that Medicare rules for 
coverage of the x-ray services have not been met. Therefore, we decided that the Plan does not have to pay for 
the x-ray services coded 71045 provided on March 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that this is medically necessary. The Plan 
denied your request. The Plan says you can be treated on BiPAP. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 portable ventilator. Our reviewer says 
that the requested ventilator is not medically necessary. Our physician reviewer found while you may benefit 
from bi-level positive airway pressure (BiPAP) treatment with average volume-assured pressure support during 
sleep, Medicare does not cover a home ventilator when used as BiPAP. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hip replacement surgery to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the OON hip replacement surgery. You say that this surgery is soon and the 
patient has no ability to walk.  Also, you stated that you believe that the requested provider is in-network. The 
Plan denied your request. The Plan says care is available from in-network providers. 
 
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 
hip replacement surgery to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 18, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed codes 
cannot be verified. 
 
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. The claim in this case was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. 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 lab services provided on August 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuous glucose monitor (CGM) supplies. 
 
You asked the Plan to pre-approve CGM supplies. You say that using the Freestyle Libre system has allowed 
you to better manage your blood glucose levels and maintain your numbers in a much more consistent fashion. 
The Plan denied your request. The Plan says that there are no records of a follow-up visit within the last 6 
months. 
 
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 you do not 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 CGM supplies have not been met. 
Therefore, we decided that the Plan does not have to pre-approve continuous glucose monitor (CGM) supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274), intraoral - 
periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230), 
periodic oral evaluation - established patient (D0120), and prophylaxis - adult (D1110) provided February 21, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that you have been seeing this dentist for years. 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 the bitewings - four radiographic images (D0274), intraoral - periapical first radiographic image 
(D0220), intraoral - periapical each additional radiographic image (D0230), periodic oral evaluation - 
established patient (D0120), and prophylaxis - adult (D1110) provided February 21, 2022, by an out-of-
network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service February 26, 
2022, to March 25, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that S9328 is billed for each 24-hour period the 
enrollee is provided with implanted pump pain management infusion. You say that S9328 is payable, and the 
claims should be reprocessed for payment. The Plan denied your request. The Plan says the billed code is 
invalid for Medicare purposes. 
 
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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service February 26, 2022, to March 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF is the most appropriate setting for the 
enrollee. The Plan denied your request. The Plan says based on Medicare guidelines, the requested IRF services 
do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee has chronic debility and requires therapy services. The necessary physical therapy and occupational therapy are available without admission to an IRF. The enrollee does not 
require more intensive therapy than can be received at other levels of care - up to an hour per day of physical 
therapy and occupational therapy. The enrollee does not require frequent physiatry oversight and does not have 
complex rehabilitation needs nor any barriers to standard rehabilitation services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an electronic connection between wheelchair controller and two or 
more power seating system motors (E2311), a harness for upgrade to expandable controller (E2313), an 
attendant control (E2331) and an expandable controller (E2377). 
 
You asked the Plan to pre-approve power wheelchair accessories. You say that the only way the member can 
live her life properly is with the powered wheelchair. The member's health is at risk, and recently had a hip 
replacement duet to her breaking it two years ago. The Plan denied your request. The Plan says that there is not 
a medical need to control these power options through the joystick. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will be covered if the patient has a mobility 
deficit that impairs their participation in MRADLs, the patients condition cannot be ameliorated by a walker, 
cane or manual wheelchair, and the patient is 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 power wheelchair accessories. Our 
reviewer says that the service is medically necessary. Our physician reviewer found clinical documentation 
shows that you have limited ROM, upper limb fracture in dominant upper limb side. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of power wheelchair accessories have been met. Therefore, we decided that the 
Plan has to pre-approve an electronic connection between wheelchair controller and two or more power seating 
system motors (E2311), a harness for upgrade to expandable controller (E2313), an attendant control (E2331) 
and an expandable controller (E2377). 
  
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 inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee was approved for 
teeth extractions and alveoloplasty and will need inpatient admission. The Plan denied your request. The Plan 
says the services are 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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the record does not show that at the time of inpatient admission the 
admitting physician reasonably expects that the enrollee's necessary hospital care will 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 not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat elevator. 
 
You asked the Plan to pre-approve a seat elevator. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you do not meet criteria for the requested device. 
 
The Plan must follow Medicare rules. Medicare rules say that power seat elevation systems are not covered.  
 
We looked at the file and Medicare rules. The requested item is specifically not covered. Based on this 
information, we decided that Medicare rules for coverage of a seat elevator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a seat elevator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 11, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the referring provider ordered the test and 
you would like the claim reprocessed. The Plan denied your request. The Plan says the rendering and referring 
providers are both OON providers and there was no approved authorization. Also, the service rendered was not 
urgent or emergent. 
 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on February 11, 
2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown on tooth #22 (D2751). 
 
You asked the Plan to pre-approve the dental services. You say that your previous crown fell out and now you 
are having difficulty chewing. The Plan denied your request. The Plan says your benefit for the requested item 
or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service November 18, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a crown on tooth #22 (D2751).