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

 
We decided that the Plan does not have to pre-approve restorative dental services for tooth #25 and #26. 
 
You asked the Plan to pre-approve restorative dental care. You say that these services are medically necessary. 
The Plan denied your request. The Plan says the requested services were not coded correctly and need to be re-
coded in order to be considered for coverage. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers restorative 
dental care when the services are medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve restorative dental care. Our reviewer 
says that requested services are not medically necessary. Our physician reviewer found there is an existing 
bridge from at least tooth #22 to tooth #25, with offset crowns on the abutments to fill the front arch spacing. 
The request for two crowns for #25 and 26 is incompatible with the existing bridge as the bridge would have to 
be sectioned to allow access to the abutment of #25, and there is no apparent abutment for #26. The rest of the 
bridge was made with the teeth offset to fill the spaces apparently made by a missing front tooth, and would be functional only as a one piece unit. The request for single unit crowns is not appropriate and the submission 
should be made again if necessary; however there is also no clear reason to replace the existing bridge units 
given the supplied x-rays. Due to the spacing (offsets) of the teeth on the abutments, replacement of two of the 
units does not appear to be possible. The existing bridge does not appear to be defective and no reason for 
replacement of it in whole or in part has been presented. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of restorative dental care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve restorative dental services for tooth #25 and #26.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Prolia injection. 
 
You asked the Plan to pre-approve a Prolia injection. The Plan denied your request. The Plan says the records 
do not show that the enrollee meets the requirements for coverage. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia injection. Our reviewer says 
that the enrollee does not meet the coverage criteria for a Prolia injection. Our physician reviewer found based 
on the medical records provided, there is no indication that the enrollee has tried and failed the required drugs. 
Our reviewer also found that there is no indication that the Plan's required drugs would likely be less effective 
and/or likely have adverse effects for the enrollee. 
 
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 Prolia injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Prolia injection.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on November 
29, 2022. 
 
You asked the Plan to waive the copayment for laboratory services. You say that your labs are covered 100%; 
therefore, you would like the claim to be covered. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $120 
copayment for Outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $120 copayment for laboratory services. This item/service falls within the 
Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for laboratory services provided on November 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a segmental gradient pressure pneumatic appliance, half leg 
(E0673) and a pneumatic compression device (E0675) provided on September 14, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and an appliance. You say that you disagree 
with the denial and have submitted medical records for review. The Plan denied your request. The Plan says 
pneumatic compression devices are covered in the home setting when medically necessary. Pneumatic 
compression devices are not covered by Medicare when the place of service is an ambulatory surgical center. 
 
The Plan follows Medicare rules. The rules say that a PCD coded as E0675 to treat peripheral arterial disease is 
not eligible for reimbursement. We looked at the file and Medicare rules. The records show that you billed with place of service 24, which is 
an ambulatory surgical center. Medicare rules state that for durable medical equipment to be covered, it must 
be appropriate and be needed for use inside the home. The pneumatic compression devices were billed for use 
outside of the home and is not separately payable.  Based on this information we decided that Medicare rules 
for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the 
Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a segmental gradient pressure pneumatic appliance, half leg (E0673) and a pneumatic compression 
device (E0675) provided on September 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued acute inpatient rehabilitation facility (IRF) 
admission and services. 
 
You asked the Plan to pre-approve continued IRF care. You say that the continued admission to an IRF is 
medically necessary. The Plan denied your request. The Plan says the continued 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 continued 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 enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the documentation does support a need for physical and/or occupational therapy, there is no documented 
need for intensive 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 continued IRF care have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing provided on November 16, 2021. 
 
You asked the Plan to pay for the panel testing. You say that the services are covered. The Plan denied your 
request. The Plan says separate payment to test the same analyte is not allowed. 
 
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 the testing was not billed with a single code as required. The lab should only report one unit of 
service of one multianalyte assay. Based on this information, we decided that Medicare rules for coverage of 
the panel testing have not been met. Therefore, we decided that the Plan does not have to pay for the panel 
testing provided on November 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 provided on September 30, 2022. 
 
You asked the Plan to pay for procedure code 99223. You say that the medical records support the billing of 
code 99223 provided on September 30, 2022. The Plan denied your request. The Plan says the medical records 
do not support the billing of code 99223 provided on September 30, 2022. 
 
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, the CPT Code Manual definition of code 99223 is Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 
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 procedure code 99223. Our reviewer says that the medical 
records do not support the billing of code 99223 provided on September 30, 2022. Our reviewer found the 
medical records provided do not include sufficient documentation to validate that the level of service described 
by code 99223 was performed on September 30, 2022, therefore this procedure cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99223 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99223 provided on September 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Vitamin D; 25 hydroxy testing (82306) provided on 
February 15, 2022. 
 
You asked the Plan to pay for the Vitamin D; 25 hydroxy testing. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says testing for screening purposes is 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, the Vitamin D; 25 hydroxy 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 Vitamin D; 25 hydroxy testing (82306) provided on February 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression devices (E0675, E0673). 
 
You asked the Plan to pay for the pneumatic compression devices. You say that the items were medically 
necessary. The Plan denied your request. The Plan says an ambulatory surgical center is not a home. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the pneumatic compression devices were used in an ambulatory surgical center. Therefore, 
we decided that the Plan does not have to pay for the pneumatic compression devices (E0675, E0673).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee arthroscopy provided on July 14, 2022. 
 
You asked the Plan to pay for the knee arthroscopy. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the knee arthroscopy 
provided on July 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the general health panel (80050) and Vitamin B-12 testing 
(82607) provided on Jun 1, 2022. 
 
You asked the Plan to pay for the general health panel and Vitamin B-12 testing. You say that these services 
were medically necessary. The Plan denied your request. The Plan says the general health panel is excluded 
from coverage and Vitamin B-12 testing is not covered as a screening test. 
 
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 rules also say that code 80050 (general health 
panel) is considered a non-covered code. 
 
The test at issue in this appeal, Vitamin B-12 testing, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Additionally,  the general health panel (80050) is not 
covered by Medicare. Therefore, we decided that the Plan does not have to pay for the general health panel 
(80050) and Vitamin B-12 testing (82607) provided on Jun 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression devices (E0675 and E0673) 
provided on September 13, 2022. 
 
You asked the Plan to pay for the pneumatic compression devices. You say that the items were medically 
necessary. The Plan denied your request. The Plan says The Place of Service billed was 24, which is an 
ambulatory surgical center. Medicare rules state that for durable medical equipment to be covered, it must be 
appropriate and be needed for use inside the home. A home may be a dwelling, an apartment, a relative's home, 
a home for the aged, or some other type of institution. Medicare does not consider an ambulatory surgical 
center a home. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the pneumatic compression devices was used in an ambulatory surgical center. Therefore, we decided that the Plan does not have to pay for the pneumatic compression devices (E0675 and E0673) 
provided on September 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation, intraoral x-ray, bitewing x-ray, 
core buildup services, guided tissue regeneration, pontic. and a bone replacement graft (D7953, D4266, D2950, 
D6245, D0120, D00220, D0230, D0274) provided on October 13, 2022, to October 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 Plan's 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 a periodic oral evaluation, intraoral x-ray, bitewing x-ray, core buildup services, guided tissue 
regeneration, pontic. and a bone replacement graft (D7953, D4266, D2950, D6245, D0120, D00220, D0230, 
D0274) provided on October 13, 2022, to October 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on June 01, 2022. 
 
You asked the Plan to pay for wound care supplies. You say that wound care supplies are a separately billable 
expense that does not require authorization or referral. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for wound care supplies 
provided on June 01, 2022.
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 has multiple on-going 
medical problems that will require daily physician involvement and assessments which will require treatment 
and requires a long-term acute level of care with a highly specialized care team. The Plan denied your request. 
The Plan says there are no services that are provided at the LTACH that could not be provided in the current 
acute care inpatient hospital setting. 
 
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 medical record does not indicate that the enrollee requires services that are 
already being received in the current facility but that would be available at the LTACH facility. 
 
 
 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a nuclear medicine study provided on 
March 18, 2022. 
 
You asked the Plan to waive the copayment for a nuclear medicine study. You say that you should not be 
responsible to pay this. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $125 
copayment for nuclear medicine. 
 
You have been asked to pay a $125 copayment for a nuclear medicine study. This item/service falls within the 
nuclear medicine benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a nuclear medicine 
study provided on March 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrodes (A4556) provided on July 14, 2022. 
 
You asked the Plan to pay for the electrodes. You say that the purpose of intraoperative spinal cord 
neuromonitoring (IONM) is to reduce the risk to the enrollee of iatrogenic damage to the nervous system 
and/or to provide functional guidance to the surgeon and anesthesiologist. The Plan denied your request. The 
Plan says procedure code A4556 has a status indicator of 'P' on the Centers for Medicare & Medicaid Services 
(CMS) Physician Relative Value File, and is always bundled into payment for other services not specified and 
no separate payment is made per Medicare. 
 
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 A4556 is not supported in the medical record. Specifically, this code has a status 
indicator of P, and no separate payment should be made for this code. Based on this information, we decided 
that Medicare rules for coverage of the electrodes have not been met. Therefore, we decided that the Plan does 
not have to pay for the electrodes (A4556) provided on July 14, 2022.