Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency services provided on August 31, 2021. 
 
You asked the Plan to pay for the services provided. You say that the medical records support the claim as 
originally submitted. The Plan denied your request. The Plan says no separate payment is made. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  In this case, the CPT Code Manual definition of code 99053 is service(s) provided between 10:00 PM and 8:00 
AM at 24-hour facility, in addition to basic service. We find that CPT code 99053 is a bundled code. When 
these services are covered, payment for them is subsumed by the payment for the services to which they are 
incident. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, 
we decided that the Plan does not have to further pay for the emergency services provided on August 31, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the crowns (D2750) for tooth #'s 3 and 4. We decided that the Plan 
does not have to pre-approve the occlusal guard (D9946).  
 
You asked the Plan to pre-approve the crowns (D2750) for tooth #'s 3 and 4 and an occlusal guard (D9946). 
You say that you have damage to tooth #3, and you also say that there is a hole in the tooth that needs to be 
addressed. The Plan says that crowns are not needed to fix your teeth, and you received a crown on tooth #4 
less than 60 months ago. The Plan also says that the occlusal guard is not covered. 
 
We decided that the Plan has to pre-approve the crowns (D2750) for tooth #'s 3 and 4.  
 
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 did not provide a copy of the applicable digital quality x-rays for this 
case. We asked for this document, but it was not provided to us. Without this information we cannot determine 
that the Plan's coverage rules support the denial of payment in this case. The Plan also did not provide us with 
any documentation showing the last date of service that the enrollee received a crown on tooth #4, exhausting 
their crown benefit for tooth #4. Consequently, the Plan has not substantiated their denial of payment in this 
case. Therefore, we decided that the Plan has to pre-approve the crowns (D2750) for tooth #'s 3 and 4.  
 
We also decided that the Plan does not have to pre-approve the occlusal guard (D9946). 
 
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 the 
occlusal guard (D9946). 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory panel rendered on August 20, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Multiplex PCR respiratory viral panels of 6 or more 
pathogens are non-covered. 
 
We looked at the file and Medicare rules. The file shows that more than 6 pathogens were tested. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pay for the respiratory panel rendered on August 20, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient visit provided on June 16, 2021.
You asked the Plan to pay for an outpatient visit. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for an outpatient visit provided on June 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (27659, 27691, 28234, 28645) provided 
October 6, 2020. 
 
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed 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 codes 27659, 27691, 28234, & 28645 are not supported in the medical record. Specifically, 
the operative report does not describe a transfer or transplant of single tendon, a flexor tendon repair, or open 
treatment of joint dislocation and internal fixation. The records describe a hammertoe repair. CPT 28234 is 
inclusive to another code billed. Based on this information, we decided that Medicare rules for coverage of the 
surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical 
services (27659, 27691, 28234, 28645) provided October 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network medical services provided to the enrollee on 
May 6, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 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 out of network medical services provided to the 
enrollee on May 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nerve block procedure (64454) performed December 14, 
2020. 
 
You asked the Plan to pay for the nerve block procedure. You say that this procedure was medically necessary. 
The Plan denied your request. The Plan says the procedure is experimental and non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the nerve block procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found genicular nerve block is considered an investigational procedure. The role of this 
procedure in the management of osteoarthritis is still being investigated. 
 
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 nerve block procedure have not been met. Therefore, we decided that the 
Plan does not have to pay for a nerve block procedure (64454) performed December 14, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services provided on August 18, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that medical records support the billed codes. The 
Plan denied your request. The Plan says the enrollee's plan requires utilization of network providers and 
authorization for certain services. 
 
 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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. 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 the pathology services provided on August 18, 2021, by an out-of-network 
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377, E2313, E2311), power 
seat elevation feature (E2300), push handles (K0108), backpack (K0108), and mounting hardware (K0108). 
 
You asked the Plan to pre-approve power wheelchair equipment. You say that these items are medically 
necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The rules say that a power seat elevation feature system will not be covered. The rules say 
that there is no separate payment for mounting hardware for a seat or back cushion. The rules say an 
expandable controller is subject to the criteria listed in the Medicare rules section. 
 
The push handles and backpack at issue in this appeal does not serve a purpose that is primarily medical in 
nature. These items are available to the general public and would be helpful even to those who are not sick or 
injured. 
 
The requested power seat elevation feature (E2300) is statutorily non covered by Medicare. In addition, the 
requested mounting hardware is not eligible for separate payment according to Medicare rules. 
 
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 for the expandable controller. Our reviewer says that 
an expandable controller is not medically reasonable and necessary. Our physician reviewer found that the 
expandable controller (E2377), expandable controller harness (E2313), and electro connect (E2311) and other 
types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head 
control, etc.) are not medically necessary per Local Coverage Article: Wheelchair Options/Accessories - Policy 
Article (A52504). The patient does not require non-proportional input devices (e.g., sip and puff, head array, 
etc.). The patient does not require a separate display (i.e., for alternate control devices), other electronic devices 
(e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant 
control. The patient has 3 power options of tilt, recline, and power elevating leg rests but the patient does not 
need to control the power options through a joystick. The patient's upper extremity strength and function 
support that the patient can control any power options through their own switches.  
 
Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377, E2313, 
E2311), power seat elevation feature (E2300), push handles (K0108), backpack (K0108), and mounting 
hardware (K0108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for blood bank physician services (CPT code 86077) provided 
on October 12, 2021. 
 
You asked the Plan to pay for the laboratory 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. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory service have not been met. As the HCPCS code 
86077 exceeded the allowable UOS of 1 for the same date of service per the MAI indicator of "2" we find that 
Medicare rule for payment of this claim has not been met. If the provider determines that a billing error 
occurred during the initial submission of the denied claim, the plan will accept a submission of a corrected 
claim to consider services for payment. Therefore, we decided that the Plan does not have to pay for blood 
bank physician services (CPT code 86077) provided on October 12, 2021.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that you came to the hospital with a prior level of
function of living alone and being modified independent with use of a 4 wheeled walker and a scooter. You say
that you are now not at this level. You say that you will need continued therapy to be able to get to your prior
level of function. The Plan denied your request. The Plan says that the guidelines for coverage of SNF care
have not been met.
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 pre-approve SNF care. Our reviewer says that the
criteria for coverage have been met. Our physician reviewer found there is documentation that daily skilled
services are required. Records document a significant decline in her functional status compared to her prior
level of functioning. At the time of her re-evaluation with therapy on March 10, 2022, the enrollee was willing
and motivated to participate with treatment and goals for her therapy over the next week were outlined. There
is documentation that the enrollee requires the services on an inpatient basis in a skilled nursing facility setting
based on her re-evaluation and willingness to participate with therapy as of March 10, 2022.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing
facility (SNF) care.
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 inpatient substance abuse rehabilitation from March 8, 
2022, forward. 
 
You asked the Plan to pre-approve inpatient substance abuse rehabilitation from March 8, 2022, forward. You 
say that the services are medically necessary. The Plan denied your request. The Plan says the services are not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that in order for an inpatient hospital stay for alcohol 
rehabilitation to be covered under Medicare it must be medically necessary for the care to be provided in the 
inpatient hospital setting rather than in a less costly facility or on an outpatient basis.  
 
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 inpatient substance abuse rehabilitation 
from March 8, 2022, forward. Our reviewer says that based upon the records provided the enrollee does not 
meet criteria for inpatient substance abuse rehabilitation from March 8, 2022, forward. Our physician reviewer 
found the enrollee was not showing any suicidal or homicidal ideation, auditory or visual hallucinations and 
was not showing any aggressive behaviors while being cooperative and compliant. He was not showing any 
symptoms of withdrawal and did not have a documented Clinical Institute Withdrawal Assessment (CIWA) 
score. The enrollee could have been treated in a lesser restrictive 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 inpatient substance abuse rehabilitation from March 8, 2022, forward have not 
been met. Therefore, we decided that the Plan does not have to pre-approve inpatient substance abuse 
rehabilitation from March 8, 2022, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified preventive procedure, by report (D1999) 
provided January 12, 2021. 
 
You asked the Plan to pay for the unspecified preventative procedure. You say that the enrollee believed the 
provider was still in-network. The Plan denied your request. The Plan says this service is not covered under the 
enrollee's benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 the unspecified preventive procedure, by report (D1999) provided January 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377, E2313, E2311) and 
attendant control (E2331). 
 
You asked the Plan to pre-approve an expandable controller. You say that this equipment is medically 
necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. The rules state that for equipment to be covered, it must be appropriate and 
needed for use inside the home. The rules say that an expandable controller is subject to the criteria listed in the 
Medicare rules section. 
 
In this case, the requested attendant control is requested specifically for use outside the home. This will not be 
covered by Medicare. 
 
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 an expandable controller. Our reviewer 
says that the requested equipment is not medically reasonable and necessary. Our physician reviewer found that 
the E2311 Electro connect btw 2 sys thru drive 2+ Actuators, E2377 Expandable Controller and E2313 
Expandable Controller Harness are not medically necessary. The requested items exceed  the patient's medical 
needs and does not meet Medicare medical necessity criteria per Local Coverage Determination (LCD): 
Wheelchair Options/Accessories (L33792) and the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Medicare Program Integrity Manual, Chapter 13, Section 13.5.4 and the Social Security Act, Section 
1862 (a)1(A) and the 42 CFR 411.15(k), 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. The patient does not require a ventilator, or non-proportional input devices (e.g., sip 
and puff, head array, etc.). The patient does not require a separate display (i.e., for alternate control devices), 
other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive 
control), or an attendant control. The patient has power options on the wheelchair, but the patient does not need 
to control the power options through a joystick. The patient's upper extremity strength supports that the patient 
can control any power options through their own 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 an expandable controller have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an expandable controller (E2377, E2313, E2311) and attendant control (E2331).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Synvisc-One. 
 
You asked the Plan to pre-approve Synvisc-One. You say that you have a history of trying other drugs that did 
not work. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, 
because the Plan requires a trial of Euflexxa before it will approve Synvisc-One. 
 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 Synvisc-One. Our reviewer says that 
you do not meet the Medicare criteria for a step therapy exception for Synvisc-One. Our physician reviewer 
found you have not tried the Plan's preferred drug of Euflexxa. The record does not show that this drug would 
likely be less effective and/or have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not 
have to pre-approve use of Synvisc-One.