Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 14 additional outpatient physical therapy visits. 
 You asked the Plan to pre-approve the outpatient physical therapy visits. You say that the extra physical 
therapy visits are medically necessary. The Plan denied your request. The Plan says they approved 4 additional 
visits and they denied the additional 14 visits as not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 outpatient physical therapy visits. 
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found the 14 visits of additional therapy are 
not medically necessary. The enrollee has been receiving physical therapy since June 14, 2022. The initial 
evaluation indicated that the enrollee had 7/10 pain. The enrollee was able to walk without an assistive device 
but has difficulty negotiating stairs. Motor strength was noted to be 4/5 bilaterally and knee flexion on the left 
was 54 degrees and 81 degrees on the right. Physical therapy notes dated September 20, 2022, indicated that 
the enrollee continued to ambulate without the use of an assistive device. Motor strength was noted to be 4/5 
bilaterally and knee flexion on the left was 58 degrees and 57 degrees on the right. 
 
The requested therapy is generally accepted as a specific and effective therapy for the enrollee's knee pain and 
osteoarthritis. The most recent documentation dated September 20, 2022, indicated that the enrollee's knee 
range of motion and motor strength was essentially unchanged. The enrollee did not have significant 
restrictions with mobility and could ambulate without an assistive device. The enrollee's progress has 
plateaued, and they can continue to make gains in terms of strength and endurance with ambulation with a 
home exercise program, for which 4 visits have been approved. The enrollee no longer requires the services of 
a skilled physical therapist. 
 
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 outpatient physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 14 additional outpatient physical therapy visits.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided on March 22, 
2022. 
 
You asked the Plan to pay for the SNF care. You say that the services which the enrollee required and received 
are coverable under the Medicare Act. The Plan denied your request. The Plan says there is no evidence of 
skilled services provided on March 22, 2022. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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 SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the skilled nursing facility (SNF) care provided on March 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair tie down kit. 
 
You asked the Plan to pre-approve the item. You say that the item is necessary. The Plan denied your request. 
The Plan says the item is not covered by Medicare or the Health Plan. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
A tie down kit is for use in transportation and not for home use. The rules state that for equipment to be 
covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use 
outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for 
use outside the home. Therefore, we decided that the Plan does not have to pre-approve wheelchair tie down 
kit.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on May 9, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says Medicare does not separately 
pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on May 9, 
2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4556 billed for date of service December 
27, 2021. 
 You asked the Plan to pay for procedure code A4556. You say that these services were medically necessary 
and are supported in the medical record. The Plan denied your request. The Plan says they have agreed to pay 
for the other services; however, procedure code A4556 is considered bundled and not separately payable. 
 
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 A4556 has a status indicator of P on the Physician Fee Schedule and was 
furnished incident to other services. This means that procedure code A4556 is not separately payable. Based on 
this information, we decided that Medicare rules for coverage of procedure code A4556 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code A4556 billed for date of service 
December 27, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 14 occupational therapy visits. 
 
You asked the Plan to pre-approve therapy visits. The Plan denied your request. The Plan says additional 
occupational therapy visits are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that you have had prior therapy and the documentation does not reveal 
that you require the unique skills of a professional therapist to provide treatment safely and effectively. The 
physician reviewer also says you have been trained in a home exercise program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapy visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 14 occupational therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341) of the 
lower right quadrant. 
 
You asked the Plan to pre-approve periodontal scaling and root planing (D4341) of the lower right quadrant. 
You say that your gums are inflamed, puffy and infected. You also say that you would like to prevent further 
issues in the mouth by having the service that is recommended approved and done. The Plan denied your 
request. The Plan says deep gum and root cleaning of the lower right quadrant (D4341) is denied due to the 
information sent by the dentist does not show this service to be medically necessary. 
 
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 periodontal 
scaling and root planing (D4341) of the lower right quadrant 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 periodontal scaling and root planing 
(D4341) of the lower right quadrant. Our reviewer says that the requested services are not medically necessary. 
Our physician reviewer found the documentation provided does not meet the criteria for coverage of scaling 
and root planing (D4341) of the lower right quadrant. 
 
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 periodontal scaling and root planing (D4341) of the lower right quadrant have 
not been met. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root 
planing (D4341) of the lower right quadrant.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87634 and 87798 billed for date of service 
February 25, 2022. 
 
You asked the Plan to pay for procedure codes 87634 and 87798. You say that the services at issue were billed 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 87634 is a column II code to column I code 87798; however, 87634 
was billed with a modifier.  
 
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 codes 87634 and 87798. Our reviewer says that 
the procedure codes at issue do not meet criteria for payment. Our reviewer found that the laboratory report 
describes testing performed on a nasopharyngeal swab by detection of nucleic acid, amplified probe 
technique. In this case, procedure code 87634 would be inclusive to code 87798, Infectious agent detection by 
nucleic acid, amplified probe technique, each organism. Modifier -59 is not supported. The laboratory report 
does not include enough documentation to confirm service reported with infectious agent, not otherwise 
specified. In this case, documentation is insufficient to verify procedure code 87798. 
 
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 codes 87634 and 87798 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 87634 and 87798 billed for date of service February 25, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that the services received were medically necessary. 
The Plan denied your request. The Plan says the provider is out-of-network, and it was determined these 
services can be received in-network. 
 
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 to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for repair blood vessel, direct; intra-abdominal (CPT code 
35221-78 X 3) provided on April 17, 2021. 
 You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Procedure code 35221-78 X 3, a direct repair of an intra-abdominal blood vessel is documented in the operative 
note submitted for review; however, this procedure is considered inclusive to CPT code 47760-78-52, an 
anastomosis, of extrahepatic biliary ducts and gastrointestinal tract; therefore, the code cannot be verified. 
Therefore, we decided that the Plan does not have to pay for repair blood vessel, direct; intra-abdominal (CPT 
code 35221-78 X 3) provided on April 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oncology (lung), mass spectrometric analysis of 
galectin-3-binding protein and scavenger receptor cysteine-rich type 1 protein M130, with five clinical risk 
factors (age, smoking status, nodule diameter, nodule-spiculation status and nodule location), utilizing plasma, 
algorithm reported as a categorical probability of malignancy (0080U). 
 
You asked the Plan to pre-approve laboratory testing. You say that the requested testing is medically necessary. 
The Plan denied your request. The Plan says you do not meet Medicare criteria for the requested laboratory 
testing. 
 
The Plan must follow Medicare rules. Medicare rules say they will provide limited coverage for the (BDX-
XL2) test for the management of a lung nodule, between 8 and 30mm in diameter, in patients 40 years or older 
and with a pre-test cancer risk (as assessed by the Mayo Clinic Model for Solitary Pulmonary Nodules) of 50% 
or less. 
 
We looked at the file and Medicare rules. The records do not show information regarding a pre-test cancer risk 
score or how the test will impact care. This is required for the test to be approved. Based on this information, 
we decided that Medicare rules for coverage of laboratory testing have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an oncology (lung), mass spectrometric analysis of galectin-3-
binding protein and scavenger receptor cysteine-rich type 1 protein M130, with five clinical risk factors (age, 
smoking status, nodule diameter, nodule-spiculation status and nodule location), utilizing plasma, algorithm 
reported as a categorical probability of malignancy (0080U).
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance services (A0427 and A0425) provided during the second 
transport to the airport on January 13, 2021. 
 
You asked the Plan to pay for the ambulance services (A0427 and A0425) provided during the second transport 
to the airport. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your 
request. The Plan says that the services are not supported in the medical records provided. 
 
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 says the records do not support the services billed in the second claim 
submitted. However, the file clearly shows that the Plan will pay for the first claim for the first transport to the 
hospital provided on June 13, 2021, from the enrollee's home. The medical records clearly show that a second 
transport was provided from the hospital to the airport. The second claim for the second transport to the airport 
is in dispute in this case as the Plan has already agreed to pay for the first claim for the first transport to the 
hospital. As the Plan's only denial rationale is that there is no record showing a second transport took place, and 
the file shows medical records of the second transport provided, we find that the Plan has not provided enough 
evidence to support their denial of payment. Therefore, we decided that the Plan has to pay for the ambulance 
services (A0427 and A0425) provided during the second transport to the airport on January 13, 2021.  
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve porcelain fused to metal crowns (D2750) for teeth #5, 
#6. 
 
You asked the Plan to pre-approve the crowns. You say that you need these services badly. The Plan denied 
your request. The Plan says a crown is not medically necessary because the tooth can be replaced by or restored 
with other material. 
 
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 the crowns 
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 the crowns. Our reviewer says that the 
requested crowns are not medically reasonable or necessary. Our physician reviewer found that there does not 
appear to be significant coronal breakdown due to caries or fracture to warrant crown restorations. 
 
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 the crowns have not been met. Therefore, we decided that the Plan does not 
have to pre-approve porcelain fused to metal crowns (D2750) for teeth #5, #6.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown - porcelain/ceramic tooth #19 (D2740), and 
periodontal scaling and root planing - four or more teeth per quadrant (D4341). 
 
You asked the Plan to pre-approve a crown - porcelain/ceramic tooth #19 (D2740), and periodontal scaling and 
root planing - four or more teeth per quadrant (D4341). You say that you would like the crown on tooth #19 to 
be approved. The Plan denied your request. The Plan says the documentation did not meet the clinical criteria 
for the services you requested. 
 
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 a crown - porcelain/ceramic (D2740), and periodontal scaling and root planing - four or more 
teeth per quadrant (D4341) 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 a crown - porcelain/ceramic (D2740), 
and periodontal scaling and root planing - four or more teeth per quadrant (D4341). Our reviewer says that the 
criteria has not been met. Our physician reviewer found on the provided x-rays there is minimal structural 
damage to tooth #19 with an existing one surface restoration and additional caries. The total destruction of 
tooth structure would be less than 25%. As tooth #19 has only one surface involvement, and possibly two after 
restoration, the Plan criteria would not be met. In this instance, the provided x-rays do not indicate a loss of 
clinical attachment which is key feature of periodontal disease. As there are no quadrants with four or more 
teeth seen with a loss of bone support indicating a loss of clinical attachment, the requested treatment under 
D4341 would not be appropriate. There is no loss of bone seen on the supplied x-rays that would indicate the 
need for the requested service. As there is no noticeable loss of attachment, the Plan criteria has not been met 
for D4341. 
 
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 a crown - porcelain/ceramic tooth #19 (D2740), and periodontal scaling and 
root planing - four or more teeth per quadrant (D4341) have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a crown - porcelain/ceramic tooth #19 (D2740), and periodontal scaling and root 
planing - four or more teeth per quadrant (D4341).