Persius/hicric huggingface dataset:
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 an IRF admission will give you better circumstances 
once you are released home. The Plan denied your request. The Plan says your records do not show that you 
need an intensive team for your care, services needed can be provided safely in other settings, a skilled nursing 
facility, home with home health services or home with outpatient therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, rehabilitation, and medical needs do not require an 
acute hospital inpatient rehabilitation stay with an interdisciplinary approach to rehabilitative 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 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: 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. The Plan denied your request. The Plan says your records show 
that you do not require an intensive and coordinated interdisciplinary approach to your rehabilitation and your 
rehabilitation is not complex, services you need can be provided safely in other settings, a skilled nursing 
facility, home with home health services or home with outpatient therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, rehabilitation, and medical needs does not 
require an acute hospital inpatient rehabilitation stay with an interdisciplinary approach to rehabilitative 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99244) with a pediatric surgeon. 
 
You asked the Plan to pre-approve an office visit with a pediatric surgeon.. You say that the service is 
medically necessary. The Plan denied your request. The Plan says there are more appropriate providers in your 
network that can provide this service. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an office visit with a pediatric surgeon. have not been met. Specifically, the requested provider is a 
pediatric surgeon that does not accept patients that are over 21 years old. You do not meet the age requirement 
to see this provider and instead the Plan has provided you with the name of doctors in your network that can 
perform this service for you. Therefore, we decided that the Plan does not have to pre-approve an office visit 
(99244) with a pediatric surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 power wheelchair rental to be supplied by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve power wheelchair rental. You say that this should be covered per Medicare 
guidelines. The Plan denied your request. The Plan says there are in-network provider that can supply this 
device. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The provider in this case is not a network provider with the Plan. The Plan has confirmed there is a network 
provider available who can provide the items at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve a group 2 
power wheelchair rental to be supplied by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair with custom seating (E1161, E1028, 
E2609, E2617, E2203, E1225, K0108). 
 
You asked the Plan to pre-approve a wheelchair with custom seating. You say that the items are medically 
necessary. The Plan denied your request. The Plan says the enrollee resides in a long term skilled nursing 
facility. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a wheelchair with custom seating is being requested for use in a SNF or hospital. Therefore, 
we decided that the Plan does not have to pre-approve a wheelchair with custom seating (E1161, E1028, 
E2609, E2617, E2203, E1225, K0108).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 9, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the claim was billed correctly and should be 
paid. 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 October 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of implant body (D6010 x 3), 
custom fabricated abutment (D6057 x 4), abutment supported crown (D6058 x 4), pontic (D6245) and bone 
replacement graft for ridge preservation (D7953). 
 
You asked the Plan to pre-approve the dental services. You say that you are a breast cancer survivor and that 
the partial replacements will not work because they will damage your teeth that are still good. The Plan denied 
your request. The Plan says the criteria for coverage of the implants was not met and some services are not 
covered 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. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
 
  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 dental services. Our reviewer says 
that you do not meet the criteria for coverage of medical necessity for the implant services. Our physician 
reviewer found that the documentation indicates multiple missing and non-restorable teeth. The enrollee 
requests implant replacement due to their history of breast cancer. History of breast cancer is not a medical 
issue that negates the use of other methods of teeth replacement such as removable appliances. The criteria for 
coverage states that fixed appliances and implants would be considered if there is a medical condition that 
contraindicates the use of an appliance(s). History of breast cancer is not a contraindication. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Additionally, D6245 and D7953 are not 
covered under any circumstance. Therefore, we decided that the Plan does not have to pre-approve a surgical 
placement of implant body (D6010 x 3), custom fabricated abutment (D6057 x 4), abutment supported crown 
(D6058 x 4), pontic (D6245) and bone replacement graft for ridge preservation (D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the biopsy of oral tissue (D7286) provided on October 20, 
2022. 
 
You asked the Plan to pay for the dental service. You say that you did not know the dentist was out-of-network 
and you would like the Plan to cover the dental services. The Plan denied your request. The Plan says the 
denial of payment for this service is correct, because the biopsy of oral tissue is not covered by the Plan. 
 
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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the biopsy 
of oral tissue (D7286) provided on October 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the inpatient L4-L5 laminectomy coded as 63047, 
63048 and 69990. 
 
You asked the Plan to pre-approve the inpatient back surgery. You say that the enrollee has severe pain and 
unable to do physical therapy due to pain. The Plan denied your request. The Plan says the enrollee does not 
meet guideline requirements and the requested back surgery 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 the back surgery. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this enrollee was being treated for spinal stenosis of the lumbar region with 
neurogenic claudication and presented with low back pain. The main problem is burning numbness in the 
bilateral feet, and poor balance. The enrollee has weakness of the right foot and has had trouble with falling. 
The exam reveals the enrollee stands and walks in flexion and has decreased range of motion in the lumbar 
spine. The enrollee is unable to stand on their heels or toes and is unable to do tandem gait. Deep tendon 
reflexes are decreased throughout. Sensory examination to light touch and pin is decreased in the lower extremities. However, detailed documentation is not evident regarding a trial and failure of recent, reasonable, 
comprehensive less invasive conservative care measures. There are limited large-scale, long-term references 
showing the safety and efficacy of the requested surgery in this clinical setting. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the requested inpatient L4-5 laminectomy, in this case, is 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 the back surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the inpatient L4-L5 laminectomy coded as 63047, 63048 and 69990.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a computed tomography (CT) scan. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the provider is out-of-
network, and it was determined these services can be received in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. Therefore, we decided that the Plan does not have to pre-approve 
a computed tomography (CT) scan to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a plastic sleeve bag with seal (E1399). 
 
You asked the Plan to pre-approve a plastic sleeve bag with seal. You say that you need this item. The Plan 
denied your request. The Plan says this item does not primarily serve a medical purpose. 
 
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 plastic sleeve bag with seal (E1399).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the subacromial decompression/acromioplasty (29826). 
 
You asked the Plan to pre-approve the subacromial decompression/acromioplasty. You say that the service is 
medically necessary. The Plan denied your request. The Plan says the service 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 the subacromial 
decompression/acromioplasty. Our reviewer says that the requested service is not considered medically 
reasonable and necessary in this case. Our physician reviewer found the records do not show that the patient 
has had adequate conservative measures for shoulder pain to include a recent trial and failure of physical 
therapy, more conservative measures including a steroid injection is needed. 
 
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 subacromial decompression/acromioplasty have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the subacromial decompression/acromioplasty (29826).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that the item is medically necessary. The Plan denied your 
request. The Plan says the member does not use insulin with at least three daily injections. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95937 provided on October 17, 2022. 
 
You asked the Plan to pay for procedure code 95937. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
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, the CPT Code Manual definition of code 95937 is Neuromuscular junction testing (repetitive 
stimulation, paired stimuli), each nerve, any 1 method.  

We find that Train of Four Testing does not fit the criteria set by CMS for CPT 95937. There is no separate 
code for Train of Four Monitoring, therefore, it would be inappropriate to bill the neuromuscular junction 
testing code for Train of Four Monitoring. 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 95937 provided on October 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the member's medical needs can be met at a lower level of care. 
 
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 is deconditioned with dementia and acute illness. Due to this, the 
enrollee would have limited capacity to participate in intensive rehabilitation. The enrollee does not require 
frequent physiatry oversight or rehabilitation nursing. Dementia can be treated in the skilled nursing facility. 
 
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 radiographic image (D0330) and 2D oral/facial 
photographic image obtained intra-orally or extra-orally (D0350) x4 provided on November 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that you do not understand how you were told you 
owe nothing, and now you are being billed for two x-rays. The Plan denied your request. The Plan says your 
benefit for the requested item or service has already been exhausted. 

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. This benefit includes the 
requested comprehensive series of radiographic images (D0210) and panoramic radiographic image (D0330) 
but is limited to one procedure code every five calendar years. The 2D oral/facial photographic image obtained 
intra-orally or extra-orally (D0350) is not covered under the Plan's dental benefits. 
 
We looked at the file, the Plan's rules, and Medicare's rules. You received covered comprehensive series of 
radiographic images (D0210) and covered panoramic radiographic image (D0330) on November 14, 2022. 
Although these are two different services, they fall within the same category in your Evidence of Coverage and 
are subject to the same frequency limitations. Therefore, these benefits were exhausted as of November 14, 
2022, because the Plan agreed to pay for D0210. Though the Plan offers a dental benefit in excess of Medicare 
coverage, the requested D0350 x4 is not among those covered under this benefit. Therefore, we decided that 
the Plan does not have to pay for 2D oral/facial photographic image obtained intra-orally or extra-orally 
(D0350) x4 and panoramic radiographic image (D0330) provided on November 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service May 31, 
2022. 
 
You asked the Plan to pay for procedure code S9328. 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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service May 31, 2022.