Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on July 17, 2021. 
 
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 were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims require distinct 5-position, alphanumeric 
home health HIPPS codes. 
 
We looked at the file and Medicare rules. The files hows that the claim was not billed with the correct HIPPS 
code. Based on this information, we decided that Medicare rules for coverage of these services have not been 
met. Therefore, we decided that the Plan does not have to pay for the home health services rendered on July 17, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS) trial. 
 
You asked the Plan to pre-approve a SCS trial. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that no payment may be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless all 
conditions are met. 
 
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 SCS trial. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee has not had an adequate work-up of her pain and has several evidence-based options before consideration of a SCS trial. The request is 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 a SCS trial have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a spinal cord stimulator (SCS) trial.
Appeal type: Other
Decision: Favorable

 
We decided that the Plan has to pay for the electrical stimulator supplies (A4595) provided on August 24, 
2022. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says that there is no 
evidence to support the ordering provider is treating the patient. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan argues that there is no evidence to support the ordering provider is 
treating the patient. However, the records show that the written order is signed by a provider of the same 
practice as the visit note for January 19, 2022. As such, the Plan has not provided documentation substantiating 
its denial, and the supplies are payable in this case. Therefore, we decided that the Plan has to pay for the 
electrical stimulator supplies (A4595) provided on August 24, 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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for two dental fillings as billed with code D2332 for date of service 
November 10, 2022. 
 
You asked the Plan to pay for the dental fillings. You say that your dentist performed fillings on two teeth with 
three surfaces of work. These fillings were billed with code D2332, but then the Plan changed the code and 
denied the claim because they do not cover the new code. The Plan denied your request. The Plan says that this 
claim was submitted with code D2332, which does not accurately describe the services performed based on the 
records provided. The services at issue are better described by code D2335 as the incisal angle was involved in 
this work. However, code D2335 is not covered by your dental benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. In addition, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the 
Plans coverage rules apply in this case. The Plan covers fillings billed with code D2332 when the services are 
medically necessary and reasonable. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, we asked our dental reviewer to carefully review the case file and 
apply the relevant Medicare rules to determine if the Plan was correct to re-code the services at issue from 
D2332 to D2335. Our reviewer found that the documentation forwarded to us was insufficient to verify 
whether or not code D2332 is inappropriate or not in this case. No dental notes were included in the case file, 
and the limited radiographs included were not sufficient to verify the Plans decision to change the coding. In 
addition, the original claim form was not forwarded to us for review, so we cannot verify which surfaces were 
reported for these fillings. The Plan has failed to forward the sufficient documentation to support their decision to re-code the services at issue. The Plan covers fillings billed with code D2332 and has provided no other 
verifiable reason for denial of these services. Therefore, we decided that the Plan has to pay for two dental 
fillings as billed with code D2332 for date of service November 10, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve catheter placement in coronary artery(s) for coronary 
angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and 
interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography 
(93458). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says cardiac catheterization is medically needed if the enrollee has high risk 
findings on the enrollee's stress test or if the enrollee is about to undergo high risk surgical procedures. The Plan states the enrollee does not have a history of coronary artery disease, the enrollee had a normal stress test, 
and the enrollee is not going to have high risk surgery. The Plan states there are other tests that the enrollee can 
have to evaluate their heart arteries that are safer. 
 
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 service. Our physician reviewer 
found guidelines do not support a need for invasive cardiac catheterization in this setting. As a result, at this 
time cardiac catheterization would not be considered medically appropriate and necessary in this enrollees 
clinical management. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve catheter placement in coronary artery(s) for coronary angiography, including 
intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart 
catheterization including intraprocedural injection(s) for left ventriculography (93458).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device provided for use during 
surgery on August 23, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that this device was provided for use 
during surgery to prevent thrombotic events. The Plan denied your request. The Plan says this device was 
provided for a non-covered purpose. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism is a preventive service.  
 
We looked at the file and Medicare rules. 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 pneumatic compression device provided for use during surgery on August 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve single-photon emission computed tomography (SPECT) 
myocardial perfusion imaging (MPI). 
 
You asked the Plan to pre-approve SPECT MPI. You say that this is needed to take a more high-definition look 
at the heart arteries to see if these deposits are large enough to be dangerous. The Plan denied your request. The 
Plan says you do not have one of the covered conditions for this testing. 
 
The Plan follows Medicare rules. Medicare rules state that MPI may be covered for certain indications. 
 
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 SPECT MPI. Our reviewer says that 
you do not meet criteria for SPECT MPI. Our physician reviewer found while imaging has shown coronary 
calcification, you have no cardiac symptoms and no exercise limitations. There is no documentation that 
electrocardiogram (EKG) shows an uninterpretable pattern or that you are unable to exercise. There is no 
evidence provided that would support the need for radionuclide stress testing at this time. There is insufficient 
documentation to support the medical necessity for this testing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SPECT MPI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve single-photon emission computed tomography (SPECT) myocardial perfusion imaging 
(MPI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) and core buildup (D2950) for tooth 
number three. 
 
You asked the Plan to pre-approve the dental services. You say that your crown broke and is causing serious 
pain. 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 April 8, 2019. Therefore, 
we decided that the Plan does not have to pre-approve a crown (D2740) and core buildup (D2950) for tooth 
number three.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 4 power wheelchair (K0885). 
 
You asked the Plan to pre-approve a group 4 power wheelchair. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that power wheelchairs are covered when specific criteria 
are met. 
 
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 group 4 power wheelchair. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found group 4 wheelchairs have added capabilities that are not needed for use in the home. Therefore, if these wheelchairs are provided 
they will be denied as not 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 a group 4 power wheelchair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a group 4 power wheelchair (K0885).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5226). 
 
You asked the Plan to pre-approve the dental services. You say that you cannot wear your current partial 
denture due to it damaging your teeth and not fitting correctly. The Plan denied your request. The Plan says this 
service is not a covered benefit 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
mandibular partial denture (D5226).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve level IV, surgical pathology (88305), 
immunofluorescence, per specimen; initial single antibody stain procedure (88346), immunofluorescence, per 
specimen; each additional single antibody stain procedure (88350), morphometric analysis; nerve (88356) 
special stain including interpretation and report; histochemical stain on frozen tissue block (88314). 
 
You asked the Plan to pre-approve testing. You say that the enrollee has very minimal tremor, with no rigidity 
or bradykinesia, and more notable for focal dystonia. Datscan was positive but had no response with levodopa, 
therefore he is considered for syn one biopsy to verify if parkinsonism is due to synucleinopathy rather than 
tauopathy. The Plan denied your request. The Plan says the requested testing does not meet Medicare criteria 
for approval. 
 
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 laboratory testing. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested services (Syn-One test) do not meet the Medicare definition of medical 
necessity. Such testing is not currently standard of care in the diagnosis of Parkinson's Disease (PD) or 
Dystonia. No diagnostic criteria for PD nor do any professional society guidelines (e.g., MDS) readily 
recommend such testing. It remains to be seen if the requested type of testing is one that is "At least as 
beneficial as an existing and available medically appropriate alternative". Nor is it clear from the literature 
available to date as to how said testing would be expected to lead to any improvements in enrollee 
management/outcomes, as it does not readily guide therapeutic decision making. In as much, this service would 
not meet the Medicare definition of medical necessity 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 testing have not been met. Therefore, we decided that the Plan does not have to 
pre-approve level IV, surgical pathology (88305), immunofluorescence, per specimen; initial single antibody 
stain procedure (88346), immunofluorescence, per specimen; each additional single antibody stain procedure 
(88350), morphometric analysis; nerve (88356) special stain including interpretation and report; histochemical 
stain on frozen tissue block (88314).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the upper 
extremity joint. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary and supported by the 
submission of clinical records. The Plan denied your request. The Plan says the records do not show a trial of a 
variety of non-surgical treatment to manage right shoulder pain. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found that in this case, the 
record indicates that the enrollee has shoulder pain. The record provided does not provide primary source 
documentation of failed conservative therapy, including physical rehabilitation. The requested service is not 
medically necessary and reasonable for the diagnosis and treatment for the enrollee's clinical condition 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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the upper extremity joint.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on July 
18, 2022. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that medically necessary services 
were provided in good faith, and you would like this claim to be processed for payment. The Plan denied your 
request. The Plan says there is inadequate documentation provided to support the medical necessity for repeat 
professional visits at a frequency exceeding Medicare guidelines. 
 
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 pay for the subsequent nursing facility care. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there was inadequate documentation provided to support the medical 
necessity for repeat professional visits at a frequency exceeding Medicare guidelines. 
 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 subsequent nursing facility care have not been met. Therefore, we decided 
that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on July 18, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from May 1, 2022, to May 
30, 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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home 
health services under a plan of treatment. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the required 032x 
TOB code. Based on this information, we decided that Medicare rules for coverage of these services have not 
been met. Therefore, we decided that the Plan does not have to pay for the home health services rendered from 
May 1, 2022, to May 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70551 billed for date of service August 4, 
2022. 
 You asked the Plan to pay for procedure code 70551. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 70551 is bundled into payment for code 
70553. 
 
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 70551 
is a column II code to column I code 70553. 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 70551 billed for date of service August 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99242) with a general surgeon to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you have a large hiatal hernia in the stomach 
which is critical, and you need to see a specialist. New symptoms have developed since initially requesting the 
service. The Plan denied your request. The Plan says you must use network providers to get your medical care 
and services. There are in-network providers available for the requested service. 
 
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 
an office visit (99242) with a general surgeon to be provided by an out-of-network (OON) provider.