Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code 85060) provided on July 
26, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the provider did not bill as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. CPT code 85060 has a 
Professional Component (PC)/Technical Component (TC) indicator of 8 per the July 2022 National Physician 
Fee Schedule Relative Value File, we find that Medicare rule for payment of this claim has not been met 
because 85060 is not payable with the billed place of service (POS) 22 for outpatient. Therefore, we decided 
that the Plan does not have to pay for the laboratory services (CPT code 85060) provided on July 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PriMatrix, per sq cm. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are no failed attempts at conservative wound 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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the records do not indicate that the enrollee has failed attempts at conservative wound 
therapy. The wounds are smaller, and there is concern for untreated infection as described by the provider on 
December 19, 2022. The provider describes concerns of inadequate offloading of pressure of your ankles while 
you are in the wheelchair. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve PriMatrix, per sq cm.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve a genicular nerve block. You say that you had surgery on your right knee 
twice, once in July and again in September and this surgery was supposed to help with your knee pain but you 
believe the knee pain is caused by the surgery and not from osteoarthritis. You say that you were approved for 
a genicular nerve block in the past, in 2022. The Plan denied your request. The Plan says genicular nerve 
blocks are not covered to treat osteoarthritis as this is considered investigation per The Centers for Medicare 
and Medicaid Services. 
 
The Plan follows Medicare rules. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a genicular nerve block. Our reviewer 
says that a genicular nerve block is not medically necessary in this case. Our physician reviewer found the 
medical records show that you had two surgeries on the right knee and had a genicular nerve block on  
June 30, 2022 that provided almost completed relief for two months. The role of genicular nerve blocks and of 
RFA is the subject of ongoing clinical trials and is considered experimental/ investigational at this time.  
Therefore, the request is considered not medically reasonable and 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 genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies (A4595) provided on June 
23, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says the written order is 
missing required information. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order. Specifically, the order is missing a date to verify the order date. The record shows that the Plan made several attempts to obtain the necessary documentation without 
success. Therefore, we decided that the Plan does not have to pay for the electrical stimulator supplies (A4595) 
provided on June 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the bedside drainage bag (CPT code 
A4357) and adhesive remover or solvent (A4455) provided on July 8, 2022; however, the Plan does have to 
reimburse you $0.66 if you have paid the coinsurance. 
 
You asked the Plan to waive the coinsurance for the DME. You say that you are appealing your cost-share 
responsibility for the services you received. 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 20% 
coinsurance for DME.  
 
Review of the file shows that you received DME on July 8, 2022. You were asked to pay 20% of the Medicare-
allowable amount for the DME. According to the Plan, they were trying to make you pay 20% of the billed 
amount instead of the allowed amount.  
 The allowed amount for A4357 is $23.38. The total you owe for A4357 is $4.68 ($23.38. x 20% = $4.68).    
 
The allowed amount for A4455 is $1.46. The total you owe for A4357 is $0.29 ($1.46. x 20% = $0.29) 
 
The total coinsurance you owe for the DME is $4.39 which is less than the $5.05 that the Plan said you had to 
pay. Therefore, the Plan has to reimburse you $0.66 if you have already made payment for the coinsurance. 
 
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 the bedside drainage bag (CPT code A4357) and adhesive 
remover or solvent (A4455) provided on July 8, 2022; however, the Plan does have to reimburse you $0.66 if 
you have paid the coinsurance.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve provision of test materials and equipment for home INR 
monitoring to be provided by the requested out-of-network provider.  
 
You asked the Plan to pre-approve provision of test materials and equipment for home INR monitoring to be 
provided by the requested out-of-network provider. The Plan denied your request. The Plan says you must use 
network providers to get health care and services when there are network providers available. 
 
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 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 provision of test 
materials and equipment for home INR monitoring to be provided by the requested out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you would benefit from SNF services. You also say 
that you have balance issues and need assistance with activities of daily living. The Plan denied your request. 
The Plan says that the admission to a SNF is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do have skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled 
nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultrasound screening for abdominal aortic aneurysms 
(AAA) (code 76706) provided on July 7, 2022. 
 
You asked the Plan to pay for the ultrasound. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the records do not show the enrollee is in one of the risk categories required 
for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the ultrasound have been met. 
Specifically, there are no medical records showing the referral from the beneficiarys physician or that the 
enrollee falls within one of the required risk categories. Therefore, we decided that the Plan does not have to 
pay for an ultrasound screening for abdominal aortic aneurysms (AAA) (code 76706) provided on July 7, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xeljanz. 
 
You asked the Plan to pre-approve Xeljanz. You say that the services are necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xeljanz.  
 
Benefits for Xeljanz may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
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 based on Medicare 
guidelines and the information we have about your condition you do not meet all the requirements. 
 
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 the intensity of services provided at an IRF. Specifically, you are 
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your 
care needs can be met 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantable neurostimulator (Reactiv8). 
 
You asked the Plan to pre-approve the service. You say that the device is for the enrollees back pain. The Plan 
denied your request. The Plan says this device has not been shown to be helpful for the enrollee's back pain 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this device is considered experimental/ investigational. Therefore, the request is deemed not 
medically reasonable and 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 service have not been met. Therefore, 
we decided that the Plan does not have to pre-approve implantable neurostimulator (Reactiv8).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 2, 2022, 
through March 31, 2022. 
 
You asked the Plan to pay for the home health services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the home health services have not been met. There is an NOA 
submitted with the "from" date as January 1, 2022, representing the continued care in 2022. However, the claim 
for the 30-day period of care, i.e., from March 2, 2022, through March 31, 2022, is submitted incorrectly with 
the admit date as December 2, 2021. Per Medicare guidelines, the HHA enters a date of admission matching 
the from date on the first date of care in an admission. On subsequent periods of care, the HHA continues to 
submit the admission date reported on the first period of care. Therefore, we find the Medicare rule for 
payment of this March 02, 2022, through March 31, 2022, claim has not been met and could not be processed 
for payment. Therefore, we decided that the Plan does not have to pay for the home health services provided 
from March 2, 2022, through March 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown - porcelain/ceramic tooth #'s 18 and 19 
(D2740), and core buildup, including any pins when required tooth #'s 18 and 19 (D2950). 
 
You asked the Plan to pre-approve the crown - porcelain/ceramic tooth #'s 18 and 19 (D2740), and core 
buildup, including any pins when required tooth #'s 18 and 19 (D2950). The Plan denied your request. The Plan 
says these services are not medically necessary. 
 
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 crown - 
porcelain/ceramic tooth #'s 18 and 19 (D2740), and core buildup, including any pins when required tooth #'s 18 
and 19 (D2950) 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 crown - porcelain/ceramic tooth #'s 
18 and 19 (D2740), and core buildup, including any pins when required tooth #'s 18 and 19 (D2950).  Our reviewer says that the documentation submitted does not support the need for buildups and crowns on 
tooth #'s 18 and 19. Our physician reviewer found the limited damage to the tooth structure would indicate a 
direct restoration would be more appropriate and cause less damage to the enamel of the tooth. In this instance 
there is minimal amounts of compromised structure, crowns would not be considered reasonable or necessary. 
A conventional directly placed restoration would be the appropriate restoration on either tooth #18 or 19. Core 
buildups are only considered where there is insufficient structure remaining to retain a necessary crown. 
 
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 crown - porcelain/ceramic tooth #'s 18 and 19 (D2740), and core buildup, 
including any pins when required tooth #'s 18 and 19 (D2950) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a crown - porcelain/ceramic tooth #'s 18 and 19 (D2740), and core 
buildup, including any pins when required tooth #'s 18 and 19 (D2950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with accessories. 
 You asked the Plan to pre-approve a group 3 power wheelchair with accessories. 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. 
 
The Plan follows Medicare rules. Medicare rules say that a power mobility device is covered when specific 
criteria are met. 
 
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 group 3 power wheelchair with 
accessories. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
enrollee does not require a group 3 wheelchair. She is not a high risk for skin breakdown and does not require 
the power tilt. She does not use intermittent catheterization, or a ventilator and does not have myopathy, 
spasticity or neurological illness as a cause of her impairment. She is weak in her extremities from unspecified 
causes. 
 
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 group 3 power wheelchair with accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 3 power wheelchair with accessories.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued SNF care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the enrollee still has the flu and is not 
able to do as much therapy for a safe return home. The Plan denied your request. The Plan says based on 
Medicare guidelines the continued skilled nursing facility care you are requesting do not meet the requirements 
for approval. 
 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 the enrollee received physical, occupational, and speech therapy. The 
enrollee was at a supervision/stand by assist to contact guard assist level with functional mobility and required 
varying assist with activities of daily living skills. The enrollee does not have daily skilled nursing needs that 
require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not 
have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. Our reviewer also found the enrollee does not require daily skilled nursing and/or skilled 
therapy on an inpatient basis in a skilled nursing facility (SNF) setting.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued SNF care.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided on March 28, 2022. 
 
You asked the Plan to pay for inpatient hospital care. You say that the services were not related to the patient's 
hospice diagnosis code as indicated by the GW modifier. 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. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for inpatient hospital care provided on March 28, 2022.