Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing visits. 
 
You asked the Plan to pre-approve home health services. You say that the services are necessary. The Plan 
denied your request. The Plan says the requested home health services are not medically necessary.  
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the home health services are not medically necessary. Our physician reviewer found the provided 
documentation does not indicate that you have documented skilled nursing needs (i.e. IVs, complex wound 
care, new TFs, new ostomy). Therefore, the reviewer found that the requested, skilled nursing visits are not 
medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve skilled nursing visits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 
24, 2021. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. 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 December 24, 
2021.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the IONM services billed with codes 95378, 95957, 95909, 95886, and 
95887. We decided that the Plan does not have to pay for the IONM services billed with G0453.  
 
You asked the Plan to pay for the IONM services. You say that this claim should be paid as billed. The Plan 
says that the denial for codes 95378, 95957, 95909, 95886, and 95887 cannot be appealed so this will be 
reviewed separately. Code 95937 was approved, and G0453 does not have the required modifier. 
 
We decided that the Plan has to pay for the IONM services billed with codes 95378, 95957, 95909, 95886, 
and 95887.  
 
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 codes at issue were denied on November 6, 2021, for requested information not being received. That such 
information was received as an appeal request would not exempt the code from an appeal determination. Since 
the Plan forfeited the opportunity to provide a valid denial rationale, we find that the denial is not substantiated. 
Therefore, we decided that the Plan has to pay for the IONM services billed with codes 95378, 95957, 95909, 
95886, and 95887.  
 
We also decided that the Plan does not have to pay for the IONM services billed with G0453. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Code G0453 is a Column 2 code in relation to code 95957. Although separate payment is allowed with a 
clinically appropriate modifier, no such modifier was reported. As such, we find that the rules for payment of 
this code have not been met. Therefore, we decided that the Plan does not have to pay for the IONM services 
billed with G0453. 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for prosthetic foot orthosis equipment (L2280, 
L1945, L2820) provided on May 21, 2021. 
 
You asked the Plan to waive the coinsurance for the prosthetic foot orthosis equipment. You say that the 
services should be covered as you disagree with the charges. The Plan denied your request. The Plan says the 
coinsurance applied correctly based on the services provided. 
 
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 20% 
coinsurance for Prosthetic devices and related supplies.  
 
 
  You have been asked to pay a 20% coinsurance for the prosthetic foot orthosis equipment (total allowed is 
$1,618 x 20% = $323). Prosthetic foot orthosis equipment falls within the Prosthetic devices and related 
supplies 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 coinsurance for prosthetic foot orthosis 
equipment (L2280, L1945, L2820) provided on May 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal distraction device. 
 
You asked the Plan to pre-approve a spinal distraction device. You say that you are in a lot of pain and cannot 
take painkillers. You say that a different back procedure was postponed so that you could get this one first. You 
say that he spinal distraction device is medically necessary. The Plan denied your request. The Plan says the 
use of the requested device for long term relief of back and leg pain is not supported. The Plan says that there 
are currently no clinical indications for this technology. 
 
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 spinal distraction device. Our 
reviewer says that a spinal distraction device is not considered medically reasonable and necessary in this case. 
Our physician reviewer found spinal distraction devices remain experimental. More research 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 a spinal distraction device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a spinal distraction device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional acupuncture visits. 
 
You asked the Plan to pre-approve acupuncture. You say that you are requesting an appeal. The Plan denied 
your request. The Plan says the denial of authorization for additional acupuncture visits is correct, because 
Medicare only covers up to 12 visits in 90 days. 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the Plan has approved 12 sessions, which is the 
maximum covered number of visits for the initial 90-day period. After this, an additional 8 visits may be 
covered if you demonstrate improvement. Please contact the Plan for more information regarding your 
treatment options. Therefore, we decided that the Plan does not have to pre-approve additional acupuncture 
visits.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic activities (97530), neuromuscular reeducation 
(97112), gait training therapy (97116), physical therapy evaluation (97162), self-care management training 
(97535), and the occupational therapy evaluation (97166) rendered by the out-of-network (OON) provider from 
February 15, 2021, through March 5, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
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 therapeutic activities (97530), neuromuscular reeducation (97112), gait 
training therapy (97116), physical therapy evaluation (97162), self-care management training (97535), and the 
occupational therapy evaluation (97166) rendered by the out-of-network (OON) provider from February 15, 
2021, through March 5, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee is at moderate risk for falling and 
will be back into the hospital. You say that the enrollee has no assistance at home and needs inpatient 
rehabilitation for hands-on assistance. The Plan denied your request. The Plan says the enrollee does not need 
daily skilled therapy services or daily skilled nursing needs. The Plan says that the enrollee's needs can be met 
at a lower level of care.  
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented 
skilled nursing needs.  The enrollee does not have documented skilled therapy needs.  The enrollee is 
ambulating more than 100 feet and tending to activities of daily living with minimal supervision.  The 
enrollees 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 21, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. 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 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 provided on June 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a stair lift and handicap accessible shower conversion 
provided on September 1, 2021. 
 
You asked the Plan to pay for stair lift and shower conversion. You say that the enrollee needs this because the 
enrollee cannot walk. The Plan denied your request. The Plan says the denial of payment for this equipment is 
correct, because this provider is not enrolled in Medicare and is not eligible for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that in order to receive payment for covered items, a 
supplier must be enrolled in Medicare.  
 
We looked at the file and Medicare rules. This equipment supplier is not enrolled in the Medicare program so is 
not eligible for payment or reimbursement. Based on this information, we decided that Medicare rules for 
coverage of stair lift and shower conversion have not been met. Therefore, we decided that the Plan does not 
have to pay for a stair lift and handicap accessible shower conversion provided on September 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 13, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. 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 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 provided on May 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete maxillary denture (D5110) provided by a 
participating provider on November 16, 2021. 
 
You asked the Plan to pay for a complete maxillary denture. You say that the first set of dentures were 
unusable. The Plan denied your request. The Plan says the benefit limit for D5110 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. The Plan covers a complete 
maxillary denture once every five years. 
 
We looked at the file and Medicare rules. Evidence was provided to show that a complete maxillary denture 
was provided on June 15, 2021. Based on this information, we decided that the Plan's rules for coverage of a complete maxillary denture have already been met. Therefore, we decided that the Plan does not have to pay for a complete maxillary denture (D5110) provided by a participating provider on November 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says a review of the current medical literature indicates that this service is considered 
experimental and investigational as it is not identified as widely used and generally accepted for the proposed 
use as reported in nationally recognized peer-reviewed medical literature. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this procedure is experimental. More research 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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from August 28, 
2021, to September 3, 2021, billed with diagnosis related group (DRG) code 304. 
 
You asked the Plan to pay for the inpatient hospital services billed with DRG 304. You say that the correct 
DRG is 304. The Plan denied your request. The Plan says DRG 304 is not supported as the diagnosis of Acute 
respiratory failure, unspecified whether with hypoxia or hypercapnia. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code, J96.01, defined as Acute 
respiratory failure, unspecified whether with hypoxia or hypercapnia. 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 inpatient hospital services billed with DRG 304. Our reviewer says that the 
submitted DRG is not supported. Our physician reviewer found that the medical records did not support the 
billing of Acute respiratory failure, unspecified whether with hypoxia or hypercapnia.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services provided from August 28, 2021, to September 3, 2021, billed with diagnosis 
related group (DRG) code 304.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for treatment of root canal obstruction (D3331) provided by an 
out-of-network provider on December 9, 2021. 
 
You asked the Plan to pay for treatment of root canal obstruction. You say that you believe this should be 
covered. The Plan denied your request. The Plan says D3331 is not a covered dental 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for treatment 
of root canal obstruction (D3331) provided by a participating provider on December 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services coded 99100 provided on September 
28, 2021. 
You asked the Plan to pay for the anesthesia services. You say that you would like this claim reprocessed based 
on the medical documentation. The Plan denied your request. The Plan says this claim has denied correctly 
based on Medicare billing rules. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the 
anesthesia services coded 99100 provided on September 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous spacer placement (22869). 
 
You asked the Plan to pre-approve the interspinous spacer placement. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 interspinous spacer placement. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the requested Vertiflex device is considered experimental. More research is 
needed to show safety and efficacy. 
 
 
 
 
 
 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 interspinous spacer placement have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an interspinous spacer placement (22869).