Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodic comprehensive preventive medicine (code 99397) 
provided on August 9, 2022. 
 
You asked the Plan to pay for periodic comprehensive preventive medicine. The Plan denied your request. The 
Plan says the service is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that when a physician furnishes a Medicare 
beneficiary a covered visit at the same place and on the same occasion as a non-covered preventive medicine 
service (CPT codes 99381-99397), consider the covered visit to be provided in lieu of a part of the preventive 
medicine service of equal value to the visit. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of periodic comprehensive preventive medicine have not been met. Therefore, we decided that the 
Plan does not have to pay for periodic comprehensive preventive medicine (code 99397) provided on  
August 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a supply allowance for therapeutic continuous glucose 
monitor (K0553) provided on March 22, 2022. 
 
You asked the Plan to pay for the continuous glucose monitor. You say that the services should be covered as 
you disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they 
do not fall within your plan benefits and do not meet the clinical requirements to be approved. 
 
  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. 
Therefore, we decided that the Plan does not have to pay for a supply allowance for therapeutic continuous 
glucose monitor (K0553) provided on March 22.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard (D9944). 
 
You asked the Plan to pre-approve an occlusal guard. You say that the requested item is a medical necessity for 
you. 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 October 25, 2021. 
Therefore, we decided that the Plan does not have to pre-approve an occlusal guard (D9944).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the lateral sacral 
branches. 
 
You asked the Plan to pre-approve RFA of the lateral sacral branches. 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 RFA of the lateral sacral branches. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found RFA of the lateral sacral branches is considered experimental because of 
the wide variation in efficacy reported in the literature. Therefore, the request is deemed not medically 
reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of RFA of the lateral sacral branches have not been met. Therefore, we decided 
that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the lateral sacral branches.
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 this service is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
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 there is not a reasonable expectation that this patient will be able to fully participate 
in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ophthalmological services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve ophthalmological services. You say that the requested services are a medical 
necessity for you. The Plan denied your request. The Plan says rules for coverage for OON care have not been 
met. 
 
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 
ophthalmological services to be provided by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360, and 88381 billed for 
date of service March 11, 2022. 
 You asked the Plan to pay for procedure code(s) 88341, 88342, 88360, and 88381. You say that you disagree 
with the denial. The Plan denied your request. The Plan says this code is included in the skilled nursing facility 
payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the SNF for its Part A inpatients and are not separately payable. 
 
The records indicate that this service was provided to the enrollee while a SNF inpatient. Per the Physician Fee 
Schedule, CPT codes 88341, 88342, 88360, and 88381 have a Professional/Technical indicator of 1. This 
means that CPT codes 88341, 88342, 88360, and 88381 have both a professional and technical component. In 
this case, CPT codes 88341, 88342, 88360, and 88381 have not been billed with an appropriate modifier to 
indicate the professional component. Based on this information, we decided that Medicare rules for coverage of 
procedure code 88341, 88342, 88360, and 88381 have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code(s) 88341, 88342, 88360, and 88381 billed for date of service March 11, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a right knee replacement. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary, as you are 
experiencing a lot of pain. The Plan denied your request. The Plan says the imaging report does not show a 
medical need for this request. 
 
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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that detailed documentation is not evident regarding which injections the enrollee has failed for the right 
knee. Additionally, the documentation does not indicate that she has limited abilities outside of noting an 
antalgic gait. There is full extension and flexion to 120. Moreover, there are no large volume, long term/high 
quality clinical studies that confirm clinical benefits (ultimate outcomes of functional improvement and pain 
reduction) of computer-assisted surgery over standard surgical approaches in total knee arthroplasty. There is 
no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested right knee replacement, in this case, is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a right knee replacement.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from February 14, 2022, to 
February 17, 2022. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that you are confident that medical 
necessity and an acute inpatient admission were supported. The Plan denied your request. The Plan says that 
the records do not show that the enrollee did not get better within 48 hours and were still a danger to themself 
or someone else, could not take care of themself, or had problems thinking clearly. 
 
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 the 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 record showed that at the time of inpatient admission the admitting physician 
reasonably expected that the enrollee's necessary hospital care (including earlier emergency department 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 the acute inpatient hospital care have been met. Therefore, we decided that the 
Plan has to pay for the acute inpatient hospital care provided from February 14, 2022, to February 17, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology services provided on June 7, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the surgical pathology services. You say that these services should be 
reimbursed. The Plan denied your request. The Plan says this service is not covered because it was provided 
OON, was referred by an OON provider, and no prior authorization was obtained. 
 
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 surgical pathology services provided on June 
7, 2022, by an out-of-network (OON) provider.
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. The Plan denied your request. The Plan says the enrollee does not 
have a complex medical diagnosis and does not require supervision by a rehabilitation physician. 
 
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 there is not a reasonable expectation that the enrollee will be able to fully participate 
in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87640 billed for date of service July 7, 2022. 
 
You asked the Plan to pay for procedure code 87640. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 87640 is bundled into payment for code 87641. 
 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 87640 
is a column II code to column I code 87641. 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 87640 billed for date of service July 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 29, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on this date 
of service and the attached reports support the level of service. You say that the claim should be reconsidered 
for processing. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment 
for code 70496.  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 procedure code 70450 billed for date of service August 29, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 76642-26-RT and 76642-26-LT billed for 
date of service September 26, 2022. 
 
You asked the Plan to pay for procedure codes 76642-26-RT and 76642-26-LT. You say that you disagree with 
the denial. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units each of 
code 76642-26-RT and 76642-26-LT, exceeding the MUE. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 76642-26-RT and 76642-26-LT have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 76642-26-RT and 76642-26-LT billed for 
date of service September 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a breast reduction surgery.  
You asked the Plan to pre-approve a breast reduction surgery. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 breast reduction surgery. Our 
reviewer says that the service is not medically necessary. Our reviewer found the objective clinical 
documentation does not support that the enrollee in this case has at least two of the coverage criteria for breast 
reduction surgery. 
 
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 breast reduction surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a breast reduction surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bifocal lens and frames provided on June 28, 2022. 
 
You asked the Plan to pay for the bifocal lens and frames. You say that you were never advised by the provider 
that there would be any additional charges. The Plan denied your request. The Plan says the claim processed 
correctly.  
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan has a $150 allowance to pay towards these services. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid $150 towards the lens and frames. This 
means you are responsible for the remaining charges. Based on this information, we decided that the Plan's 
rules for coverage of the bifocal lens and frames have not been met. Therefore, we decided that the Plan does 
not have to pay for the bifocal lens and frames provided on June 28, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal aortic ultrasound rendered on August 15, 
2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
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, these services, was requested solely for screening purposes. The services were 
billed with diagnosis code Z13.6 (encounter for screening for cardiovascular disorders), which is not a 
diagnosis for which an abdominal aortic ultrasound is covered. Medicare does not cover this test solely for 
screening purposes. Therefore, we decided that the Plan does not have to pay for the abdominal aortic 
ultrasound rendered on August 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on October 28, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the lab testing. You say that this testing should have been paid in full. The Plan 
denied your request. The Plan says this service is not covered because it was provided OON without prior 
authorization. 
 
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 lab testing provided on October 28, 2022, by 
an out-of-network (OON) provider.