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

 
We decided that the Plan does not have to pay for laboratory services (procedure code 87491 and 87640) 
rendered on August 29, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that in 
terms of CPT 87491, the records do not contain a result for this infectious agent. It cannot be verified that this 
test was performed.   
In terms of CPT 87640, our reviewer found that it is not supported as a separately identifiable and distinct 
procedure from CPT 87641. The record shows that these tests are related and should not be reported separately. 
 
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 pay for laboratory services (procedure code 87491 and 87640) rendered on August 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body (6010 x2), surgical 
stent (D5982 x2), bone graft (D6104 x2), implant/abutment supported removable denture (D6111), semi-
precision attachment (D6191 x2, D6192 x2). 
 
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied 
your request. The Plan says the requested services are not covered 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. 
 
   
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 
surgical placement of implant body (6010 x2), surgical stent (D5982 x2), bone graft (D6104 x2), 
implant/abutment supported removable denture (D6111), semi-precision attachment (D6191 x2, D6192 x2).
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 01916-AA-P3. We decided 
that the Plan does not have to pay for the services described by procedure code(s) 99100-GY.  
 
You asked the Plan to pay for practitioner services provided on July 1, 2023, billed with procedure codes 
01916-AA-P3 and 99100-GY. You say that the claim is billed correctly and should be paid. The Plan says that 
code 99100-GY is considered bundled and is not separately payable. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 01916-AA-P3.  
 
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 01916-AA-P3.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
99100-GY. 
 
The Plan follows Medicare rules. Medicare rules say that the Physician Fee Schedule Status Indicator B means 
that payment for covered services is always bundled into payment for other services not specified. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services described by procedure code(s) 99100-GY have not been met. Therefore, we decided 
that the Plan does not have to pay for the services described by procedure code(s) 99100-GY. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implanted loop recorder (ILR). 
 You asked the Plan to pre-approve the requested ILR procedure. You say that this is medically necessary. The 
Plan denied your request. The Plan says the enrollee has not had a 30-day event monitor and there is no 
documentation of cryptogenic cerebrovascular accident (CVA) or syncope. 
 
The Plan must follow Medicare rules. Medicare rules say ILR placement may be considered medically 
necessary when it is needed to evaluate syncope that is thought to be cardiac-related but occurs too infrequently 
to be detected by traditional external monitors.  
 
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 requested ILR procedure. Our 
reviewer says that the requested ILR procedure is not medically reasonable and necessary based on NCD 
criteria. Our physician reviewer found the enrollee has no history of recent unexplained syncope, or CVA and 
has not had 30 days of noninvasive heart monitoring. 
 
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 requested ILR procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of an implanted loop recorder (ILR).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid examination and selection (92591) provided 
on September 15, 2023. 
 
You asked the Plan to pay for the hearing aid examination and selection. You say that you were not aware you 
would be charged for this service. The Plan denied your request. The Plan says this is not covered under the 
medical benefit. You can use your Quartz CashCard toward hearing aid costs. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan pays for 
hearing aids and related services under your $1,000 Quartz CashCard benefit.  
 
   
We looked at the file and the Plans rules. The hearing aid examination and selection services in dispute are 
considered hearing aid related services. These types of services are only covered under your contract when 
using your Quartz CashCard. The case file provided shows that, at the time of the Plans appeal review, you 
had $613.68 remaining on your Quartz CashCard. You would need to contact the provider and pay the bill with 
your Quartz CashCard in order to utilize the coverage allowed for the hearing aid services. There is no benefit 
for direct payment from the Plan to the provider for hearing aids and hearing aid related services. Therefore, we 
decided that the Plan does not have to pay for the hearing aid examination and selection (92591) provided on 
September 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (80048 and 85027) provided on 
September 15, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and would not be 
bundled to any other procedure on this date. The Plan denied your request. The Plan says the enrollee was 
admitted to a skilled nursing facility (SNF) at the time of services, and the payment for these tests would be 
included in the payment to the SNF. The Plan must follow Medicare rules. Medicare rules say that the payment for laboratory services provided to a 
Medicare beneficiary enrolled in a Part A covered SNF stay is included in the payment to the SNF facility.  
 
We looked at the file and Medicare rules. The enrollee was in a Part A covered inpatient SNF stay at the time 
of services. This means that the payment for these services would be included in the payment to the SNF 
facility and would be paid by the facility under arrangements to the laboratory. Based on this information, we 
decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that 
the Plan does not have to pay for laboratory services (80048 and 85027) provided on September 15, 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 you are eager to get back to your baseline after your 
injury. The Plan denied your request. The Plan says you do not meet the criteria for admission to an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve upgraded electronics (E2311, E2313, E2377), and push 
handles (K0108). 
 You asked the Plan to pre-approve the power wheelchair features. You say that the need for the power 
wheelchair is justified along with her diagnosis, to operate the power wheelchair the upgraded electronics are 
needed for actuators. The Plan denied your request. The Plan says the notes do not show a medical need to 
control the power options through the joystick. The Plan also says that the push handles do not serve a medical 
purpose and therefore cannot be covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Additionally, for equipment to be covered, it must primarily serve a medical 
purpose. 
 
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 power wheelchair features. Our 
reviewer says that the requested upgraded electronics are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the provided records indicate that the enrollee does have use of the 
upper extremity and can operate and control the power options using the switches that are included in the basic 
wheelchair. There is not a medical need for upgraded electronics. Therefore, the reviewer found that the 
requested upgraded electronics are 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 upgraded electronics have not been met. Additionally, the requested push 
handles do 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 upgraded electronics (E2311, E2313, E2377), and push handles (K0108).
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 enrollee is expected to benefit from the services 
available at an IRF. The Plan denied your request. The Plan says an IRF admission is not medically necessary, 
but skilled therapies as an outpatient, home with home healthcare, or continuing at a skilled nursing facility 
(SNF) may be approved upon request.  
 
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, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable and there are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthofix Trinity Elite allograft. 
 
You asked the Plan to pre-approve Orthofix Trinity Elite allograft. You say that this is medically necessary. 
The Plan denied your request. The Plan says the required 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 Orthofix Trinity Elite Allograft. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is limited literature that shows this requested allograft to be an 
effective or safe treatment for the noted pathology. Further studies are needed to demonstrate this service has 
beneficial outcomes compared with conventional treatment. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthofix Trinity Elite Allograft have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Orthofix Trinity Elite allograft.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve continued SNF care. You say that you would like to be able to continue with 
your rehabilitation to maintain strength and not lose the progress you have currently made. The Plan denied 
your request. The Plan says continued admission in a SNF does 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 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; however, further 
improvement in your functional status does not appear to be predictable in a reasonable time frame to 
necessitate further daily skilled therapy services, and transition to part-time therapy services now appears to be 
appropriate. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled 
nursing facility (SNF) setting. The records support that services in the long-term care facility on a part-time 
basis are appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: 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 enrollee requires inpatient rehabilitation in order 
to regain maximum functionality. The Plan denied your request. The Plan says that the rules for IRF admission 
have not all been met, and the enrollee's needs can be met at an alternate 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 complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
requires treatment by multiple therapies, including physical therapy and occupational therapy, but this can be 
provided in a lower level of care. There is documentation that there is a reasonable expectation that this 
enrollee will be able to fully participate in  and benefit from  the intensive rehabilitation therapy program 
provided in an IRF, but the services required can 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 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that denying LTACH care will jeopardize the 
enrollee's life and ability to regain function. You say that the enrollee is not clinically appropriate for a lower 
level of care and is ready for discharge to an LTACH. The Plan denied your request. The Plan says an LTACH 
admission is not medically necessary. 
 
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 enrollees needs are currently being met in the acute care hospital and transfer to 
an LTACH would not provide any new services.  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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve destruction. 
 
You asked the Plan to pre-approve genicular nerve destruction. You say that this is medically necessary. The 
Plan denied your request. The Plan says there is insufficient evidence in medical literature to support this 
request. 
 
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 genicular nerve destruction. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is considered an experimental therapy that is the subject of ongoing 
clinical trials. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular nerve destruction have not been met. Therefore, we decided that the 
Plan does not have to pre-approve genicular nerve destruction.