Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service August 20, 
2022. 
 
You asked the Plan to pay for procedure code 86077. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable 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. 
 
In this case, the CPT Code Manual definition of code 86077 is blood bank physician services; difficult cross 
match and/or evaluation of irregular antibody(s), interpretation and written report. 
 
We find that CPT code 86077 is not supported in the medical record. Specifically, this service was billed with a 
place of service 11 (office); however, the documentation shows that the enrollee was inpatient for this date of 
service. Based on this information, we decided that Medicare rules for coverage of procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 86077 billed for 
date of service August 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network (OON) dentist 
on October 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that the Plan did not offer a dentist that could 
provide these services. The Plan denied your request. The Plan says the dental services were received from an 
out-of-network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided by an out-of-network (OON) dentist on October 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on June 22, 2022, by an out-
of-network (OON) provider. 
   
You asked the Plan to pay for wound care supplies. You say that you would like the claim reprocessed for 
payment. The Plan denied your request. The Plan says the provider is not a network provider, and the services 
were not referred by a network provider. The services were not urgent or emergent, nor were they approved in 
advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for wound care supplies provided on June 22, 2022, 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) 
provided on December 14, 2022. 
 
You asked the Plan to pay for the limited oral evaluation - problem focused. You say that you were not told 
that this exam was not covered and that you would be responsible for the amount due. You also say that since 
you were not told this service was not covered you do not believe you should have to pay the total balance. The 
Plan denied your request. The Plan says this service is not covered under the benefit package when the service 
is performed by a dentist and not an oral surgeon. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a limited 
oral evaluation - problem focused (D0140) provided on December 14, 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. The Plan denied your request. The Plan says the 
enrollee is receiving appropriate in-patient acute care and does not require transfer to a Long-Term Acute Care 
Hospital. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan. 
 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: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve moderate sedation (99152) for the approved procedure. 
 
You asked the Plan to pre-approve moderate sedation (99152) for the approved procedure. You say that the 
requested moderate sedation (99152) for the approved procedure is medically necessary. The Plan denied your 
request. The Plan says that the requested moderate sedation (99152) for the approved procedure is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 moderate sedation (99152) for the 
approved procedure. Our reviewer says that the requested moderate sedation (99152) for the approved 
procedure is medically necessary. Our physician reviewer found the enrollee has a central pain syndrome 
following a stroke. He also has lumbar radiculopathy. The request is for monitored sedation during the 
procedure. Central pain syndrome is a difficult medical problem to manage and to sedate adequately. It requires 
a separate provider to provide sedation. The request is 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 moderate sedation (99152) for the approved procedure have been met. 
Therefore, we decided that the Plan has to pre-approve moderate sedation (99152) for the approved procedure.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. 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 must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found you are to undergo a procedure which is not on the inpatient only list and is 
not expected to require two midnights of inpatient level care. There is no documentation of uncontrolled co-
morbidities pre-procedure, which clearly necessitate a prolonged stay. You should present for, undergo and bee 
monitored following the procedure. Should complications arise that necessitate a prolonged stay, you can be 
converted to inpatient status at that time under the two-midnight rule. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the acute inpatient hospital care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on May 7, 2021, through 
May 9, 2021, and billed with diagnosis code J96.01. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
secondary diagnosis J96.01 is supported by the records. The Plan denied your request. The Plan says the 
documentation submitted does not support secondary diagnosis of J96.01. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code J96.01-Acute respiratory 
failure with hypoxia. 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 inpatient hospital 
services at the DRG originally billed. Our reviewer says that the documentation does not support the secondary 
diagnosis of J96.01, Acute respiratory failure with hypoxia. Our physician reviewer found the member was 
diagnosed with acute pulmonary embolism after workup. There was no baseline of arterial blood gas (ABG). 
The member's partial pressure of carbon dioxide (PCO2) level was 37.1, partial pressure of oxygen (PO2) level 
was 52.5, and pulmonary hypertension (PH) level was 7.398, which is insufficient evidence of acute respiratory 
failure compared to the member's baseline. Therefore, diagnosis code J96.01-Acute respiratory failure with 
hypoxia is not the appropriate secondary diagnosis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on May 7, 2021, through May 9, 2021, and billed with diagnosis code 
J96.01.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires assistance with activities of 
daily living (ADL) and ambulation and meets all criteria for an IRF admission. The Plan denied your request. 
The Plan says based on the records received, an IRF admission is not supported. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. 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 an IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a custom fabricated abutment  includes placement (D6057), 
and abutment supported porcelain fused to metal crown (noble metal) (D6061) provided on December 27, 
2022. 
 
You asked the Plan to pay for the dental services represented by codes D6057 and D6061. You say that the 
crown should be covered whether it be for a natural tooth or an abutment and would like to know why it is not 
covered. You also say that it is about the same cost. The Plan denied your request. The Plan says these services 
are not covered under the benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a custom 
fabricated abutment  includes placement (D6057), and abutment supported porcelain fused to metal crown 
(noble metal) (D6061) provided on December 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that an inpatient stay at a rehabilitation facility is 
medically necessary and the best treatment option for you. The Plan denied your request. The Plan says your 
records do not show you need an intensive team for your care, services you need can be provided safely in 
other settings, a skilled nursing facility, home with home health services, or home with outpatient services. 
 
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 the enrollee does not have complex or intensive therapy needs and does not require 
frequent physiatry oversight. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the electrical connection between the wheelchair 
controller and two or more motors (E2311), expandable controller (E2377), harness (E2313), and power seat 
elevation system (E2300). 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that the items are medically necessary. 
The Plan denied your request. The Plan says the items are not medically necessary. 
 
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 wheelchair accessories. Our 
reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the member has adequate upper body strength to manage standard power switches. 
 
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 wheelchair accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the electrical connection between the wheelchair controller and two or more 
motors (E2311), expandable controller (E2377), harness (E2313), and power seat elevation system (E2300).
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 is 
medically stable and does not meet the medical necessity criteria for IRF. 
 
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 the enrollee has chronic deconditioned state with an additional acute decline, does 
not require intensive rehabilitation services to regain function and does not have complex needs nor does he 
require frequent physiatry oversight. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ankle-control orthosis (L4350) provided on May 18, 2022. 
 
You asked the Plan to pay for an ankle-control orthosis. You say that the item at issue has been 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. The rules also say that no additional codes may 
be billed with code L4631. 
 
We find that CPT code L4350 is not supported. Specifically, the case record documents that code L4631 was 
billed for the same date of service. No additional codes may be billed with code L4631. Based on this information, we decided that Medicare rules for coverage of an ankle-control orthosis have not been met. 
Therefore, we decided that the Plan does not have to pay for an ankle-control orthosis (L4350) provided on 
May 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism. 
 
You asked the Plan to pre-approve a seat lift mechanism. You say that the item is medically necessary. The 
Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section 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 seat lift mechanism. Our reviewer 
says that you do not need this item. Our physician reviewer found you do not have the inability to rise from a chair in your home nor do you have severe arthritis or a neuromuscular condition preventing mobility. 
 
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 seat lift mechanism have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a seat lift mechanism.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation-problem focused (D0140) provided 
on May 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. 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 February 24, 2022. 
Therefore, we decided that the Plan does not have to pay for limited oral evaluation-problem focused (D0140) 
provided on May 4, 2022.