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

 
We decided that the Plan does not have to pay for periodontal scaling and root planing - one to three teeth, per 
quadrant (D4342) and debridement of a peri-implant defect or defects surrounding a single implant, and surface 
cleaning of the exposed implant surfaces, including flap entry and closure (D6101) provided on March 9, 2022, 
to May 18, 2022. 
 
 You asked the Plan to pay for dental services. You say that the enrollee had numerous periodontal abscesses 
forming around the teeth/implants and that the enrollee needed the provided services. The Plan denied your 
request. The Plan says this service is not covered under your Plan. 
 
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. Periodontal scaling and root 
planing - one to three teeth, per quadrant (D4342) and debridement of a peri-implant defect or defects 
surrounding a single implant, and surface cleaning of the exposed implant surfaces, including flap entry and 
closure (D6101) are not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested peri-implant defect or 
defects surrounding a single implant, and surface cleaning of the exposed implant surfaces, including flap entry 
and closure (D6101) are not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pay for periodontal scaling and root planing - one to three teeth, per quadrant (D4342) and 
debridement of a peri-implant defect or defects surrounding a single implant, and surface cleaning of the 
exposed implant surfaces, including flap entry and closure (D6101) provided on March 9, 2022, to May 18, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that you need more intense therapy so you can recover. The Plan denied your request. The Plan says the Medicare guidelines for IRF admission were not met and the enrollee can receive the care they need at a skilled nursing facility.

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 was admitted to the hospital on October 25, 2022, for a left hip fracture and underwent surgical fixation. The enrollee has not had a significant change in his baseline medical conditions other than the fracture of his hip and does not require the intensity of rehabilitation physician oversight provided in the acute inpatient rehabilitation setting. The enrollee does not require rehabilitation nursing for complex wound care, parenteral nutrition or tube feedings, tracheostomy management or bowel and bladder management. The enrollee's medical and rehabilitation needs do not require the intensive interdisciplinary approach provided on acute inpatient rehabilitation.

The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program at least 3 hours a day and 5 days a week, or 15 hours over 7 consecutive days. As of October 27, 2022, the enrollee required set up assistance for grooming and upper body bathing and minimal assistance for upper body dressing. The enrollee required moderate assistance for transfers and walking 3 feet with a hemi-walker. The enrollee has had a functional decline from his baseline level of function and would likely benefit from therapy, but they do not require the intensity of therapies provided on acute inpatient rehabilitation.

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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0483) provided on April 7, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (G0483) provided on April 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental crown, filling, nerve treatment, and nerve canal 
repair (D2954, D2750, D3310, D3346) 
 
You asked the Plan to pre-approve the dental crown, filling, nerve treatment, and nerve canal repair. You say 
that the services should be covered as you disagree with the denial. The Plan denied your request. The Plan 
says the services denied correctly as they do not fall within your dental 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. 
 
 
  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 
dental crown, filling, nerve treatment, and nerve canal repair (D2954, D2750, D3310, D3346)
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee fully meets the Medicare criteria for IRF admission. The Plan denied your request. The Plan says admission to the IRF did not meet the Medicare criteria and the enrollee can receive the care that they need at a skilled nursing facility.

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 currently resides in a group home setting with 24-hour supervision. The enrollee has not had a significant change in their baseline medical conditions other than their stage IV pressure wound and does not require the intensity of rehabilitation physician oversight provided in the acute inpatient rehabilitation setting. The enrollee does not require rehabilitation nursing for parenteral nutrition or tube feedings, tracheostomy management or bowel and bladder management. The enrollee's medical and rehabilitation needs do not require the intensive interdisciplinary approach provided on acute inpatient rehabilitation.

The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program at least 3 hours a day and 5 days a week, or 15 hours over 7 consecutive days. The enrollee currently requires a wheelchair for mobility and maximum assistance for transfers and with daily activities. The enrollee has had a functional decline from their baseline level of function, but it is unlikely that they can participate in and benefit from the intensity of therapies provided on acute inpatient rehabilitation.

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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiation oncology, image guided radiation therapy 
(IGRT). 
 
You asked the Plan to pre-approve image guided radiation therapy. You say that please review, reprocess and 
approve according to contract as a medical necessity. The Plan denied your request. The Plan says IGRT is not 
medically necessary for superficial radiation therapy. 
 
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 image guided radiation therapy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found usually IGRT is used when critical structures are abutting or in close 
proximity to the target that is being treated to high doses. This situation does not apply to this enrollee for which the target lesion can be seen on the skin to assist in daily set up. When treating skin cancers, there is 
generally not a need for IGRT unless deep structures are being treated. Certainly, using ultrasound on a daily 
basis is not unreasonable to offer but not necessary. Therefore, to bill for daily simple simulations and/or IGRT 
for a technology for which need has not been established by published data or supported by consensus 
guidelines (many of which recommend against treatment with these devices in general) is not necessary. My 
decision is unfavorable as billing for daily simulations (also requested in this case) or IGRT would not be 
furnished in accordance with accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of image guided radiation therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve radiation oncology, image guided radiation therapy (IGRT).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service December 
22, 2021. 
 You asked the Plan to pay for procedure code 93010. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment for code 93010 is bundled into 
payment for code 36556. 
 
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 93010 
is a column II code to column I code 36556. 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 93010 billed for date of service December 22, 
2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 99601 billed for date of service July 7, 2022.

You asked the Plan to pay for procedure code 99601. You say that services were provided in good faith. 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 99601 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code 99601 is not valid for Medicare purposes. 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 pay for procedure code 99601 billed for date of service July 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says admission to the IRF was denied as not meeting criteria, is not medically necessary, and a lower level of care might be appropriate. Skilled nursing facility level of care was offered.

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 was admitted to an acute hospital on October 29, 2022, after a fall sustaining multiple lacerations, sprain at left ankle and knee and eyelid. The enrollee was noted to have an acute kidney injury, acute on chronic low back pain, and elevated blood pressure. There are no complex nursing or rehabilitation needs. While the enrollee has a need for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 71045 billed for date of service May 22, 2022.

You asked the Plan to pay for procedure code 71045. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says payment for code 71045 is bundled into payment for code 74022.

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 71045 is a column II code to column I code 74022. 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 71045 billed for date of service May 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient psychiatric care from January 1, 2022, through January 25, 2022.

You asked the Plan to pay for inpatient psychiatric care from January 1, 2022, through January 25, 2022. You say that the services at issue were medically necessary. The Plan denied your request. The Plan says the services at issue were not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 

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 inpatient psychiatric care from January 1, 2022, through January 25, 2022. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental health treatment from January 1, 2022, through January 25, 2022. Our physician reviewer found the enrollee did not require inpatient mental health treatment from January 1, 2022, through January 25, 2022, as he was not a danger to himself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis.

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 psychiatric care from January 1, 2022, through January 25, 2022, have not been met. Therefore, we decided that the Plan does not have to pay for inpatient psychiatric care from January 1, 2022, through January 25, 2022.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane (J7318).

You asked the Plan to pre-approve Durolane. The Plan denied your request. The Plan says the enrollee does not have any stated contraindications to, nor have they tried the preferred products. The Plan also says that a rationale is not provided for use of the non-preferred product for safety or efficacy.

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 Durolane. Our reviewer says that the enrollee does not meet the criteria for coverage for Durolane. Our physician reviewer found the requested medication is a new start. The provided records do not indicate that the enrollee has tried and failed the Plan's preferred step one alternative. Our reviewer also found that the record does not indicate that the enrollee has a contraindication to, or would have an adverse effect from the Plan's preferred step one alternative.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane (J7318).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy-duty walker without wheels rigid or folding (E0148).

You asked the Plan to pre-approve a heavy-duty walker. You say that one leg is bigger than the other. You also say you sometimes fall and need a heavy-duty walker to catch yourself. The Plan denied your request. The Plan says you do not meet coverage criteria for approval of a heavy-duty walker.

The Plan must follow Medicare rules. Medicare rules say that a heavy-duty walker is covered for beneficiaries who meet coverage criteria for a standard walker and who weigh more than 300 pounds.

We looked at the file and Medicare rules. The records show that your current weight is 245 pounds. Medicare rules say you must meet the weight requirement for the requested walker. Medicare rules also say that if you weigh less than 300 pounds, the walker will be denied as not reasonable and necessary. Based on this information, we decided that Medicare rules for coverage of a heavy-duty walker have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy-duty walker without wheels rigid or folding (E0148).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure codes S9500 and S9501 billed for date of service March 24, 2022, to March 25, 2022.

You asked the Plan to pay for the billed services. You say that the codes are valid. 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 codes S9500 and S9501 have a Status Indicator of I on the Physician Fee Schedule. This means that the codes are not valid for Medicare purposes. 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 pay for procedure codes S9500 and S9501 billed for date of service March 24, 2022, to March 25, 2022.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 76700 billed for date of service June 28, 2022.

You asked the Plan to pay for procedure code 76700. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says payment for code 76700 is bundled into payment for code 93976.

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 76700 is a column II code to column I code 93976. 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 76700 billed for date of service June 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a platelet rich plasma injection.

You asked the Plan to pre-approve a platelet rich plasma injection. You say that you are in pain and joint replacement is expensive and carries a higher risk factor. The Plan denied your request. The Plan says a platelet rich plasma injection is 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 a platelet rich plasma injection. Our reviewer says that a platelet rich plasma injection is not considered medically reasonable and necessary. Our physician reviewer found this is an experimental/investigational procedure. Therefore, the request is deemed not medically reasonable or 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 a platelet rich plasma injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a platelet rich plasma injection.