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

 
We decided that the Plan does not have to pay for procedure code 93976 billed for date of service April 30, 
2022. 
 
You asked the Plan to pay for procedure code 93976. You say that you disagree with the denial. 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 30, 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 the enrollee is stable for discharge, and 
clearly exceeds the criteria for an appropriate LTACH. The Plan denied your request. The Plan says this is not 
medically necessary, and continued acute hospital stay was offered, until the member could discharge to a 
lower level of care. 
 
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 the requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
 
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services provided on May 9, 2022, by an 
OON provider. 
 
You asked the Plan to pay for ophthalmological services. You say that you had an emergency while out of 
town. You say that you did not contact the Plan prior to receiving services from an out-of-network provider 
your sister recommended. 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 ophthalmological services provided on May 9, 
2022, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87640 billed for date of service June 6, 2022. 
 
You asked the Plan to pay for procedure code 87640. You say that these services are supported as billed. The 
Plan denied your request. The Plan says payment for code 87640 is bundled into payment for code 87641. 
 
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 87640 is a column II code to column I code 87641. 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 87640 billed for date of service June 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an outpatient clinic visit (code G0463) 
provided on March 26, 2021, and testing materials and equipment for home monitoring (code G0249) provided 
on December 14, 2021. 
 
You asked the Plan to waive the copayments for a clinic visit and home monitoring services. You say that you 
should not be responsible for the $45 copayments. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for each physician specialist service.  You have been asked to pay a $45 copayment for a clinic visit provided on March 26, 2021. According to 
Medicare, testing materials and equipment for home monitoring (code G0249) is a physician service. You have 
also been asked to pay a $45 copayment for home monitoring services provided on December 14, 2021. These 
items/services fall within the physician services benefit category. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayments for an outpatient clinic visit (code G0463) provided on March 26, 2021, and testing materials and 
equipment for home monitoring (code G0249) provided on December 14, 2021.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 you do 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 you 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic and intraoral x-rays and dental extractions 
provided on May 26, 2022 to June 2, 2022.  
 
You asked the Plan to pay for the panoramic and intraoral x-rays and dental extractions. You say that these 
services were medically necessary and should be covered. The Plan denied your request. The Plan says the 
extractions were covered with the correct cost-sharing. The intraoral and panoramic x-rays are not a covered 
benefit.  
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 x-rays performed are not among 
those covered under this benefit. Only bite-wing x-rays are covered. The plan contract states that there is a 50% 
coinsurance for simple extractions. The cost of the extractions was $88. The plan covered $44 and the enrollee 
is responsible for the remaining $44 coinsurance. The cost-sharing was applied correctly. Therefore, we 
decided that the Plan does not have to pay for panoramic and intraoral x-rays and dental extractions provided 
on May 26, 2022 to June 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service April 15, 
2022. 
 
You asked the Plan to pay for procedure code 99100. The Plan denied your request. The Plan says procedure 
code 99100 is considered bundled and not separately payable. 
 
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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable.  Based on this information, we decided that Medicare rules for coverage of procedure code 99100 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 99100 billed for date of 
service April 15, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One. 
 
You asked the Plan to pre-approve Gel-One. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 Gel-One. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the medical records provided and 
the Medicare-approved major drug compendia there is no indication that the plan's required drugs would likely 
be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a principal care management service visit provided on June 
20, 2022, by an OON provider. 
 
You asked the Plan to pay for a principal care management service. You say that you are appealing as the 
services were rendered in a nursing facility. 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 a principal care management service provided on 
June 20, 2022, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 69990 billed for February 23, 2022. 
 
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 procedure code 69990 is not separately payable. 
 
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 69990 
is a column II code to column I code 36224 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 69990 billed for February 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a backup battery for a Continuous Positive Air Pressure 
(CPAP) machine (E1399). 
 
You asked the Plan to pre-approve the battery backup. You say that your electrical service is unreliable and the 
battery is medically necessary. The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a backup battery for a Continuous Positive Air Pressure 
(CPAP) machine (E1399).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not 
meet criteria. 
 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 continued SNF care. Our reviewer says 
that the requested SNF care is not considered medically reasonable and necessary based on Medicare 
guidelines. Our physician reviewer found you do not have documented skilled nursing needs or documented 
skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent 
deterioration of your condition. Your care needs, custodial and intermittent, can, as a practical matter, be 
provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an insertion, subcutaneous cardiac rhythm monitor, 
including programming (33285). 
 
You asked the Plan to pre-approve an implantable loop recorder (ILR). You say that the requested monitor is 
medically necessary. The Plan denied your request. The Plan says the requested monitor does not meet the 
requirements for approval. 
 
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 an implantable loop recorder (ILR). 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has a history of atrial fibrillation. There is no 
documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent 
indication for an ILR. In summary, there is insufficient documentation to support the medical necessity for 
insertion of an ILR in the enrollees clinical management. 
 
 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 implantable loop recorder (ILR) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an insertion, subcutaneous cardiac rhythm monitor, including 
programming (33285).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic laboratory testing coded as U0003 and U0005 
provided February 1, 2022. 
 
You asked the Plan to pay for the diagnostic testing. You say that you provided services in good faith that you 
would be reimbursed at your published rate of $100. 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 
members terminal condition. 
 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 the diagnostic laboratory testing coded as U0003 and U0005 
provided February 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulation of one or more of the extra-spinal 
regions (head region; lower extremities; upper extremities; rib cage; abdomen) provided on May 2, 2022. 
 
You asked the Plan to pay for chiropractic manipulation of one or more of the extra-spinal regions (head 
region; lower extremities; upper extremities; rib cage; abdomen). You say that the service was medically 
necessary. The Plan denied your request. The Plan says Medicare does not cover chiropractic treatments to 
extraspinal regions, which includes the head, upper and lower extremities, rib cage and abdomen. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for chiropractic manipulation of one or more of the extra-spinal regions (head 
region; lower extremities; upper extremities; rib cage; abdomen) provided on May 2, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Octagam (CPT code J1568). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee does not have any stated contraindications to the preferred products. 
The enrollee has not tried any of the preferred agents. The provider does not provide a rationale 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 the medication. Our physician reviewer 
found the provided records do not indicate that the enrollee has tried and failed the plan's preferred step one 
alternative. 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. The elements of the coverage criteria are not satisfied. The 
requested service cannot be recommended. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Octagam (CPT code J1568).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantable loop reader (ILR) (CPT code 33285). 
 You asked the Plan to pre-approve the implantable loop reader. You say that the enrollee passes out and has 
dizziness. The Plan denied your request. The Plan says the enrollee's request is not medically necessary 
because their records show there is not a question as to whether they have atrial fibrillation. The Plan states the 
enrollee's doctor does not indicate that the replacement Loop monitoring test results would impact their medical 
management. 
 
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 implantable loop reader. Our 
physician reviewer found there is insufficient documentation to support the medical necessity for insertion of 
an ILR in this enrollee's clinical management. 
 
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 implantable loop reader have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the implantable loop reader (ILR) (CPT code 33285).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from March 1, 2022, to 
March 22, 2022. 
 
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 claims were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that a RAP and a claim must be submitted for all episodes 
for which Medicare makes payment based on HIPPS codes. 
 
We looked at the file and Medicare rules. The file shows that a RAP was not submitted timely for these 
services. 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 home health services rendered from 
March 1, 2022, to March 22, 2022.