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

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and a bitewing x-ray 
(D0270) provided on May 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says your benefit for the requested items or services 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 items or services was exhausted on date of service April 5, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) and a bitewing 
x-ray (D0270) provided on May 4, 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 the records provided support the need for IRF care. 
The Plan denied your request. The Plan says the requirements for coverage of IRF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found 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 was admitted for respiratory failure and pneumonia. The enrollee's medical problems are stable. There are no 
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93976 billed for date of service April 20, 
2022. 
 You asked the Plan to pay for procedure code 93976. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 93976 is bundled into payment for 
code 76856. 
 
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 93976 
is a column II code to column I code 76856. 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 93976 billed for date of service April 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on April 12, 2022, by an OON 
provider. 
 
You asked the Plan to pay for laboratory services. The Plan denied your request. The Plan says the out-of-
network services were not authorized. 
 
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 laboratory services provided on April 12, 2022, by 
an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair (PWC) with multiple power 
options represented by code K0861, and related accessories represented by codes E2361, K0108, E1028, 
E2377, E2313, E1007, E2620, E2311, E0955, E1028, E1012, E0956, K0040, and E2607. 
 
You asked the Plan to pre-approve a group 3 PWC with multiple power options and related accessories. You 
say that the records provided support the need for the items in dispute. The Plan denied your request. The Plan 
says you do not have a medical need for multiple power options included with the requested PWC. 
 
The Plan follows Medicare rules. Medicare rules say that Group 3 PWCs are covered for certain medical 
indications. Medicare rules also say that if the PWC base is not covered, then related accessories will be 
denied. 
 
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 3 PWC with multiple power 
options and related accessories. Our reviewer says that the criteria for coverage have not been met. Our 
physician reviewer found the records provided do support the need for a group 3 power wheelchair, but do not 
support the need for the multiple power options. Records do not support that you are high risk for skin 
breakdown, have a history of pressure ulcer(s) or have had skin flap surgery. Records do not document that you 
perform bladder self-catheterization and are unable to transfer independently or that you have increased muscle 
tone or spasticity to meet the requirements for the power tilt/recline and multiple power options. The records 
also do not document that you have a musculoskeletal condition or the presence of a cast or brace which 
prevents 90-degree flexion at the knee, or that you have significant edema of the lower extremities that requires 
an elevating leg rest. As the group 3 power wheelchair with multiple power options does not meet Medicare 
criteria for reasonable and necessary, none of the requested accessories meet requirements for coverage. 
 
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 3 PWC with multiple power options and related accessories have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair (PWC) 
with multiple power options represented by code K0861, and related accessories represented by codes E2361, 
K0108, E1028, E2377, E2313, E1007, E2620, E2311, E0955, E1028, E1012, E0956, K0040, and E2607.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided from June 25, 2021, to 
December 14, 2021 by an out-of-network provider. 
 
You asked the Plan to pay for chiropractic services. The Plan denied your request. The Plan says non-emergent, 
non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for chiropractic services provided from June 25, 2021, to  
December 14, 2021 by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis 51 or greater genes 
(81455) provided April 12, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that  The Plan denied your request. The Plan 
says does not meet Medicare NCD/LCD criteria. 
 
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 find that CPT code 81455 is not supported in the medical record. Specifically, the claim was billed with a date of service inconsistent with Medicare rules governing laboratory services. The specimen was 
collected on April 1, 2022, rather than the billed date of service April 12, 2022. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided 
that the Plan does not have to pay for targeted genomic sequence analysis 51 or greater genes (81455) provided 
April 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the supporting information provided 
demonstrates that the enrollee clearly meets Food and Drug Administration (FDA) indications for use of the 
requested treatment. The Plan denied your request. The Plan says the services in dispute are not a covered 
benefit. 
 
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 Intracept procedure. Our reviewer 
says that the Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental. More research is needed to show safety and 
efficacy of the procedure to treat back pain. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee is in desperate need of the 
requested ventilator because he is not breathing well on his own. You say that the enrollee's carbon dioxide 
(CO2) levels are very low and that he is on a high liter flow of Oxygen. You say that the enrollee has apnea. 
The Plan denied your request. The Plan says the requested device is not medically necessary because the 
records do not show that the enrollee has severe lung disease. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found the prescription documents a 
diagnosis of chronic obstructive pulmonary disease (COPD.) The case file does not contain sufficient documentation of chronic respiratory failure. The prescription indicated the ventilation mode is to be average 
volume-assured pressure support (AVAPS-AE), or intelligent volume-assured pressure support (IVAPS-AE), 
or tracheal transport velocity volume-assured pressure support (TTV-VAPS-AE.) Products classified as code 
E0466 when used to provide continuous positive airway pressure (CPAP) or bi-level positive airway pressure 
(BiPAP) (with or without backup rate) therapy, regardless of the underlying medical condition, shall not be 
paid. The denial of an E0466 Home ventilator used with noninvasive interface which is a mechanical ventilator 
with functionality that exceeds that of an E0470 or E0471 device, is consistent with Medicare regulations. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns - porcelain/ceramic (D2740) tooth #'s 23, 24, 25, 
and 26. 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial and would 
like the Plan to reconsider coverage. 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 May 16, 2022. Therefore, 
we decided that the Plan does not have to pre-approve crowns - porcelain/ceramic (D2740) tooth #'s 23, 24, 25, 
and 26.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crutch substitute (E0118) you purchased on April 13, 
2022. 
 
You asked the Plan to pay for the crutch substitute. You say that this was an emergency because you were in 
Germany.  In order to move around and be able to return home for surgery, you needed to purchase this item.  
You said that using crutches was unsafe. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that that knee scooters and other crutch substitutes 
are not covered for any indication. Therefore, we decided that the Plan does not have to pay for the crutch 
substitute (E0118) you purchased on April 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computerized knee and replacement foot (L5950, 
L5856, L5828, L5848, L5845, L5980, L5986). 
 
You asked the Plan to pre-approve a computerized knee and replacement foot. You say that the prosthetics are 
medically necessary. The Plan denied your request. The Plan says a request for a microprocessor knee and 
advanced foot does not meet Medicare criteria as reasonable and 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 a computerized knee and replacement 
foot. Our reviewer says that the requested items/services are not considered medically reasonable and necessary 
in this case. Our physician reviewer found a computerized knee and replacement foot exceed your medical 
needs, as Medicare does not pay for any items or services that are not reasonable and necessary for the 
diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Your 
current knee and foot are still under warranty therefore it is not medically necessary to have replacement parts 
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 [Shorter description of ITEM or SERVICE at issue, e.g. "a power wheelchair"] 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a computerized knee and 
replacement foot (L5950, L5856, L5828, L5848, L5845, L5980, L5986).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77062 billed for date of service March 1, 
2022. 
 
You asked the Plan to pay for procedure code 77062. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 77062 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 77062 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 77062 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 77062 billed for date of service March 1, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code T2046 billed for date of service July 30, 
2021 to August 27, 2021. 
 
You asked the Plan to pay for procedure code T2046. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 T2046 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code T2046 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code T2046 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code T2046 billed for date of service July 30, 2021 to August 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the contact lens fitting provided on April 11, 2022. 
 
You asked the Plan to pay for the contact lens fitting. You say that you had a routine eye exam with your 
contacts in and then with your contacts out. You say that you did not purchase any contact lenses and you did 
not have a contact lens fitting. The Plan denied your request. The Plan says the service is not a covered benefit. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan does not cover contact lens fittings. 
 
We looked at the file and the Plan's rules. Specifically, the contact lens fitting is not a covered benefit. Based 
on this information, we decided that the Plan's rules for coverage of the contact lens fitting have not been met. 
Therefore, we decided that the Plan does not have to pay for the contact lens fitting provided on April 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from August 7, 2021, 
to August 11, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient services at the DRG originally billed. You say that this claim was 
billed correctly. The Plan denied your request. The Plan says the diagnosis code of N30.00 (acute cystitis 
without hematuria) is not supported in the medical record. This diagnosis was removed, resulting in a lower 
DRG. 
 
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 the diagnosis code of N30.00 (acute cystitis without 
hematuria). 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 services at the DRG 
originally billed. Our reviewer says that the diagnosis code of N30.00 (acute cystitis without hematuria) is not 
supported in the medical record. Our physician reviewer found the enrollee was a then, a 91-year-old female 
who presented to the facility following a mechanical fall at home. The past medical history included 
hypertension, hyperlipidemia, non-insulin dependent type 2 diabetes, paroxysmal atrial fibrillation, and 
coronary artery disease. On presentation, the patient reported acute on chronic back pain and acute right and 
left hip pain which was attributed to the mechanical fall. There were no acute fractures found on imaging, and 
the patient was cleared by trauma services. The patient was also found to be in atrial fibrillation and required 
treatment with IV Metoprolol and IV Cardizem. While documentation also indicated a diagnosis of E. coli 
acute cystitis, the clinical evidence did not support the condition.  
 
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 the inpatient hospital services provided from August 7, 2021, to August 11, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 15, 2022 billed with 
codes March 15, 2022. 
 
You asked the Plan to pay for the genetic testing billed. You say that 81455, 81301, 81194, 81479 and 81436 
should not be considered a diagnostic service but a prognostic indicator service that aids the treating provider 
with selecting the right cancer treatment options. The Plan denied your request. The Plan says does not meet 
Medicare NCD/LCD criteria. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 15, 2022 billed with codes March 15, 2022.