Persius/hicric huggingface dataset:
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 IRF admission is medically necessary, and you 
would like reconsideration based on the records submitted. The Plan denied your request. The Plan says criteria 
for admission to the IRF 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 that the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program at least three hours a day and five days a week, or 15 hours over seven consecutive days. Currently, the enrollee requires minimal 
assistance for bed mobility, moderate assistance for transfers and contact guard assistance when ambulating 
with a walker. The enrollee has had a decline from his baseline level of function and would benefit from 
therapy, but he does not require the intensity of therapies provided on acute inpatient rehabilitation. Therefore, 
the IRF admission is not medically 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83550 billed for date of service January 4, 
2022. 
 
You asked the Plan to pay for procedure code 83550. The Plan denied your request. The Plan says this 
procedure code is not paid separately. 
 
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 83550 is a column II code to column I code 84466 with a modifier 
indicator of 0. The column II code is therefore not payable. 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 83550 
billed for date of service January 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve linx access key, circuit breaker, charger cable, charger 
cable extension, and safety audio alert. 
 You asked the Plan to pre-approve the electronic accessories. You say that these accessories are needed for the 
lithium battery to work. You also say that the battery was approved. The Plan denied your request. The Plan 
says the requested items are not medical in nature and therefore are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The items at issue in this appeal do not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve linx access key, circuit breaker, charger cable, charger cable 
extension, and safety audio alert.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device to be provided at the 
in-network benefit level by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve pneumatic compression device. You say that you are the only provider in 
the area specializing in the needed brand of pneumatic compression pump. The Plan denied your request. The 
Plan says this provider is out-of-network with the Plan and the needed equipment can be supplied within the 
Plan network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that enrollees may choose to receive covered items and services from either in-network or out-of-
network providers. Enrollees must pay 20% coinsurance for in-network DME or 50% coinsurance for out-of-
network DME. 
 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 at the in-network benefit level. The enrollee may choose to utilize 
this provider at the out-of-network benefit level. Therefore, we decided that the Plan does not have to pre-
approve a pneumatic compression device to be provided at the in-network benefit level 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 comprehensive oral evaluation (D0150), panoramic 
radiographic imaging (D0330), a 2D oral image (D0350), adjunctive pre-diagnostic test (D0431), and 
diagnostic casts (D0470), provided on September 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you needed these services. The Plan denied 
your request. The Plan says these services have been processed correctly. 
 
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 D0150 and D0330 was exhausted on date of service June 15, 2022. D0350, D0431, and 
D0470 are not covered dental benefits. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), panoramic radiographic imaging (D0330), a 2D oral image (D0350), 
adjunctive pre-diagnostic test (D0431), and diagnostic casts (D0470), provided on September 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cataract surgeries provided on March 23, 2022, to April 
06, 2022. 
 
You asked the Plan to pay for the cataract surgeries. You say that you informed the provider that authorization 
was required, and it was their responsibility to obtain it. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the cataract surgeries 
provided on March 23, 2022, to April 06, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 04, 2022. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on October 04, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve K3 ankle and foot features for a lower limb prosthesis (L5981, 
L5986). 
 
You asked the Plan to pre-approve the K3 ankle and foot features. You say that these features are medically 
necessary. The Plan denied your request. The Plan says that the requested features exceed the enrollee's 
functional abilities. 
 
The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of foot. This 
information must be retained in the treating practitioner's or prosthetist's files. 
 
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 K3 ankle and foot features. Our 
reviewer says that these features are medically necessary. Our physician reviewer found the documentation 
provided does support the use of the requested K3 prosthetic foot ankle components. There is sufficient 
documentation regarding the patients potential functional level. The enrollee has the capacity to walk with 
variable cadence and both the prosthetic and clinical documentation support this. 
 
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 K3 ankle and foot features have been met. Therefore, we decided that the 
Plan has to pre-approve K3 ankle and foot features for a lower limb prosthesis (L5981, L5986).  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service November 
15, 2022. 
 
You asked the Plan to pay for procedure code 76642. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76642 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76642 billed for date of 
service November 15, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service June 17, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on this date 
of service and the attached reports support the level of service. You say that the claim should be reconsidered 
for processing. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment 
for code 70496.  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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service June 17, 2022.
Appeal type: Lab
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 October 5, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. 
 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 October 
5, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the electrical stimulator supplies provided on September 20, 2022. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says that the proof of 
delivery did not include an order number or details to corroborate the delivery ticket submitted. 
 
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 the proof of delivery did not include an order number or 
details to corroborate the delivery ticket submitted. However, the records contain an itemized packing slip 
dated September 20, 2022, with the same tracking number as the delivery ticket dated September 24, 2022. As 
the documentation shows that the items in question were delivered, the Plan's denial cannot be substantiated. 
Therefore, we decided that the Plan has to pay for the electrical stimulator supplies provided on September 20, 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture - flexible base (D5225). 
 
You asked the Plan to pre-approve the maxillary partial denture - flexible base (D5225). You say that you 
cannot have the traditional hard base denture is because it is not compatible with the fixed bridge that is already 
in your mouth. The Plan denied your request. The Plan says this service is 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 pre-approve a 
maxillary partial denture - flexible base (D5225).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99310 billed for date of service August 22, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the medical records illustrate the need for the 
services. The Plan denied your request. The Plan says there is a more appropriate code to describe the services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99310 is not supported. The claim billed a place of service code 13, indicating an 
assisted living facility. There is a more appropriate code available to describe evaluation and management 
services provided in an assisted living facility.  
 Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 99310 billed for date of 
service August 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary. The Plan denied your 
request. The Plan says a trial of Zoledronic Acid is required before Prolia can be considered. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that Prolia is 
not medically necessary. Our physician reviewer found the record does not show a trial of the plan preferred 
drug or any reason it would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on October 05, 2022. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on October 05, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 02, 2022. 
 
You asked the Plan to pay for an office visit. You say that due to Covid-19 we had limited providers in the 
office, along with other staff, and are asking for reconsideration. The Plan denied your request. The Plan says 
that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on September 02, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for coverage. 
 
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 is no evidence that the enrollee requires services that are not currently 
available.  As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in 
transferring the enrollee to the LTACH.  
 
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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of torus mandibularis (D7473), and 
alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant (D7320). 
 
You asked the Plan to pre-approve the removal of torus mandibularis (D7473), and alveoloplasty not in 
conjunction with extractions - four or more teeth or tooth spaces, per quadrant (D7320). 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 pre-approve 
removal of torus mandibularis (D7473), and alveoloplasty not in conjunction with extractions - four or more 
teeth or tooth spaces, per quadrant (D7320).