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

 
We decided that the Plan does not have to pay for the localized delivery of antimicrobial agents and periodontal 
maintenance (D4381, D4910) provided on October 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. 
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the localized delivery of antimicrobial agents and periodontal maintenance (D4381, D4910) provided 
on October 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
September 22, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service September 22, 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 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 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 intensive rehabilitation to recover from a hip fracture. You do not 
require frequent physiatry oversight. Hip fracture rehabilitation does not require an IRF admission. You have no medical barriers to standard post hip fracture rehabilitation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), an expandable 
controller (E2377), and an access harness upgrade (E2313). 
 
You asked the Plan to pre-approve codes E2311, E2377, and E2313. You say that the records provided support 
the need for the items which remain in dispute. The Plan denied your request. The Plan says upgraded 
electronics are not covered unless there is a medical need to control power options through the joystick. The 
Plan says that the notes do not show a medical need to control the power options through the joystick. 
 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 codes E2311, E2377, and E2313. Our 
reviewer says that the items which remain in dispute are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has adequate strength to manage standard power switches 
on power 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 codes E2311, E2377, and E2313 have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an electronic connection (E2311), an expandable controller (E2377), and 
an access harness upgrade (E2313).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653 and 87798 billed for date of 
service May 12, 2022. 
 
You asked the Plan to pay for procedure codes 87481, 87653 and 87798. You say that these services were 
reported correctly. The Plan denied your request. The Plan says these services are not supported for separate 
payment. 
 
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 codes 87653 and 87481 are both column II codes to column I codes 87150 
and 87801. These services have not been billed with an appropriate modifier to bypass the edit. Based on the 
claim submitted, Medicare billing criteria have not been met for codes 87653 and 87481. In addition, we have 
confirmed that code 87798 is a column II code to column I code 87801; however, 87798 was billed with a 
modifier.  
 
We asked our coder 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 procedure code 87798. Our reviewer says that the use of 
modifier 91 is not supported in this case. Our reviewer found the record does not support that any of the tests 
performed that were reported with code 87798 needed to be repeated. These tests are included in code 87801 as 
the code description states, "multiple organisms", so testing for individual/unspecified organisms is not 
supported. There is no evidence that these tests needed to be collected or performed more than once for this 
date of service. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87481, 87653 and 87798 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 87481, 87653 and 87798 billed for date of 
service May 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve calf rest/pads, detachable armrests, and an electronic 
connection. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The items at issue in this appeal do not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve calf rest/pads, detachable armrests, and an electronic 
connection.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve seven home health physical therapy visits. 
 You asked the Plan to pre-approve home health services. You say that the requested services are medically 
necessary. The Plan denied your request. The Plan says the 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 services are not medically reasonable and necessary. Our physician reviewer found that you do not 
have documented skilled therapy needs. You are functioning at a level appropriate for a lower level of care. As 
such, the requested, ongoing, home health physical therapy services 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 seven home health physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a median nerve block (66450). 
 
You asked the Plan to pre-approve a median nerve block. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the median nerve injection cannot be approved because, per clinical policy, 
there is not enough evidence to show that this procedure is safe and that it works well for pain. 
 
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. Medicare rules state that experimental and investigational devices are 
not covered. There is not enough evidence to show that this procedure is safe and works well for pain. Based 
on this information, we decided that Medicare rules for coverage of a median nerve block have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a median nerve block (66450).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150-91, 87481, 87653, 87798-91, 87801-
91, and 87641-91 billed for date of service June 29, 2022. 
 
You asked the Plan to pay for procedure codes 87150-91, 87481, 87653, 87798-91, 87801-91, and 87641-91. 
The Plan denied your request. The Plan says the codes remain not supported. 
 
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 codes 87150-91, 87481, 87653, 87798-91, and 87641-91 are column II 
codes to column I codes 87801 and 87150. The codes at issue have not been billed with an appropriate modifier 
to bypass the edit. Furthermore, the records do not show that code 87801, billed with the 91 modifier, was a 
repeat procedure. 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 codes 87150-91, 87481, 87653, 87798-91, 87801-91, 
and 87641-91 billed for date of service June 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve partial psychiatric hospitalization. 
 
You asked the Plan to pre-approve partial psychiatric hospitalization. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have 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 partial psychiatric hospitalization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found based upon review of the records provided, you do not meet the criteria for 
treatment at partial hospitalization level of care and could have been treated in a lesser restrictive setting. You 
were not showing any suicidal or homicidal ideation and not showing any psychosis or aggressive behaviors. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of partial psychiatric hospitalization have not been met. Therefore, we decided that 
the Plan does not have to pre-approve partial psychiatric hospitalization.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary for the 
enrollee's recovery. The Plan denied your request. The Plan says the enrollee's care can be completed in a lower 
level of care such as an inpatient rehabilitation facility or a skilled nursing facility. 
 
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 record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services.   The enrollee continues to receive acute care services, and these have not been 
denied.  The medical record does not indicate that the enrollee requires services that they are not currently 
receiving but that would be available at the LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 20 additional physical therapy visits. 
 
You asked the Plan to pre-approve the 20 additional physical therapy visits. You say that the total requested 
number of physical therapy visits are necessary to help the enrollee return to the prior level of function and gain 
ease with activities of daily living. The Plan denied your request. The Plan says the physical therapy visits 
which remain in dispute are not medically necessary.  
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 20 additional physical therapy 
visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found the additional requested therapy 
generally is not accepted as specific and effective therapy for the patient condition beyond what was approved 
by the health plan. The patient has had prior therapy and the documentation does not reveal that the patient 
requires the unique skills of a professional therapist to safely and effectively provide treatment, that the 
services can be safely and effectively performed only by a therapist, or by or under the supervision of a 
therapist. The requested services are not part of a maintenance program, and the specialized skill, knowledge 
and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain 
the patient's current condition or to prevent or slow further deterioration. The patient can transition safely to an 
independent home exercise program with the 4 additional improved therapy sessions. The documentation does 
not support a need for 20 more supervised therapy sessions. 
 
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 20 additional physical therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 20 additional physical therapy visits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323). 
 
You asked the Plan to pre-approve Euflexxa. You say that the requested drug is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the enrollee has not tried and failed the 
preferred drugs. 
 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 Euflexxa. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed one of the plan's preferred drugs. The reviewer found that the 
documentation does not indicate that the enrollee has a contraindication to or would have an adverse effect 
from one of the plan's preferred drugs. Therefore, the reviewer found that the step therapy criteria have not 
been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa (J7323).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the upper 
extremity. 
 
You asked the Plan to pre-approve the MRI. You say that you have pain in the left shoulder, and you need to 
find out why. The Plan denied your request. The Plan says the enrollee has not completed 6 weeks of provider 
directed treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI. Our reviewer says that the 
MRI of the upper extremity is not medically necessary. Our physician reviewer found that the record indicates 
that the enrollee has shoulder pain. The record does not indicate that the enrollee has any red flag signs or 
symptoms or neurologic deficit. The record does not indicate that the enrollee has had plain films or has failed 
a trial of conservative therapy. The requested service is not medically necessary and reasonable for the 
diagnosis and treatment for the enrollee's clinical condition at this time. The elements of the coverage criteria 
are not satisfied. 
 
  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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of the upper extremity.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the post and core in addition to crown, indirectly 
fabricated (D2952). 
 
You asked the Plan to pre-approve the post and core in addition to crown, indirectly fabricated (D2952). You 
say that you need a root canal and crown on your front tooth. The Plan denied your request. The Plan says this 
service is not covered under the benefit package. 
 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
post and core in addition to crown, indirectly fabricated (D2952).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration-resorbable barrier, per site 
(D4266 x 4). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested services 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 requested services are not among 
those covered under this benefit.  
 
 
 
 
  
Therefore, we decided that the Plan does not have to pre-approve guided tissue regeneration-resorbable barrier, 
per site (D4266 x 4).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of 
the spinal cord provided by an in-network provider on October 13, 2022. 
 
You asked the Plan to waive the copayment for the magnetic resonance imaging (MRI) of the spinal cord. You 
say that you were billed incorrectly. 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 $180 
copayment for in-network advanced imaging services provided in a specialist's office. 
 
You have been asked to pay a $180 copayment for the magnetic resonance imaging (MRI) of the spinal cord. 
This item/service falls within the outpatient diagnostic tests and therapeutic services and 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 copayment for the magnetic resonance imaging (MRI) of the 
spinal cord provided by an in-network provider on October 13, 2022.