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

 
We decided that the Plan does not have to pre-approve crowns (D2740) for tooth #3 and #13. 
 
You asked the Plan to pre-approve the crowns. You say that your provider says there is recurrent decay. The 
Plan denied your request. The Plan says the records do not indicate the criteria was met. 
 
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 crowns 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 crowns. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found a review of the documentation indicates the 
presence of crowns on teeth #'s 3 and 13. These crowns appear adequate and there was no narrative indicating 
the reason for the replacement. 
 
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 crowns have not been met. Therefore, we decided that the Plan does not 
have to pre-approve crowns (D2740) for tooth #3 and #13.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365 and 96374 billed for date of service 
October 26, 2022. 
 You asked the Plan to pay for procedure code 96365 and 96374. The Plan denied your request. The Plan says 
payment for codes 96365 and 96374 is bundled into payment for code 93015. 
 
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 
96365 and 96374 are column II codes to column I code 93015. 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 96365 
and 96374 billed for date of service October 26, 2022.
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 cannot be safely discharged home. You require 
SNF care in order to get stronger and let your cellulitis heal. The Plan denied your request. The Plan says the 
request 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 not have daily 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), 
expandable controller (E2377), attendant control (E2331), Q-Logic 3 joystick armor (K0108), Accu-Trac motor 
upgrade (K0108), and occupied transit option kit (K0108). 
 
You asked the Plan to pre-approve an electronic connection, harness, expandable controller, attendant control, 
Q-Logic 3 joystick armor, Accu-Trac motor upgrade, and occupied transit option kit. You say that the enrollee 
is on a fixed income and the requested wheelchair is more affordable with another company. The Plan denied 
your request. The Plan says although there are three requested power options (tilt, recline and elevating leg 
rests), there is not a medical need to control these power options through the joystick. An attendant control 
cannot be covered in addition to a beneficiary-operated joystick. The Plan says that a joystick controller display 
is part of the Expandable Controller should not be requested separately. The Accu-Trac motor upgrade (K0108) 
exceeds the enrollee's need and cannot be approved. The Plan also says that a transit option does not serve a 
medical need and cannot be covered. 
 
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 an electronic connection, harness, 
expandable controller, attendant control, Q-Logic 3 joystick armor, Accu-Trac motor upgrade, and occupied 
transit option kit. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the enrollee has sufficient strength and function in 
their upper extremities to manage standard power drives. The Accu-Trac facilitates steering and is not 
medically necessary as there is no evidence the enrollee cannot steer the power wheelchair. Our reviewer also 
found that the occupied transit kit is for transport and is not medically necessary for MRADLs in the home.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection, harness, expandable controller, attendant control, Q-
Logic 3 joystick armor, Accu-Trac motor upgrade, and occupied transit option kit have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311), harness 
(E2313), expandable controller (E2377), attendant control (E2331), Q-Logic 3 joystick armor (K0108), Accu-
Trac motor upgrade (K0108), and occupied transit option kit (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (K0800). 
 
You asked the Plan to pre-approve a power scooter. You say that a power scooter is medically necessary. The 
Plan denied your request. The Plan says the coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power scooter. Our reviewer says that 
the coverage criteria has not been met. Our physician reviewer found that there is a lack of clinical 
documentation indicating your level of mobility and physical examination findings, specifically with regards to 
motor strength in the upper and lower extremities. You are noted to have 4-5/5 motor strength in the lower 
extremities. You are also noted to have osteoarthritis of the hip and knee joints, but there is no indication that 
you cannot use a cane or walker for assistance with mobility or propel a manual wheelchair. There is also a 
lack of information as to whether you can safely operate the requested power scooter. 
 
 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 power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter (K0800).
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 service are medically necessary. The Plan denied 
your request. The Plan says the enrollee does 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 the enrollee is medically stable. There are no acute rehab nursing needs identified or 
documented. The complexity of the enrollee's medical, rehab, and nursing needs does not require an acute 
hospital inpatient rehab stay with an interdisciplinary approach to rehabilitative care. The enrollee's rehab needs 
can be safely provided in an alternate and low intensity 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 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse (RN) 
in the home health or hospice setting, each 15 minutes (G0299). 
 You asked the Plan to pre-approve home health services. You say that you are requesting reconsideration. 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 clinical 
documentation specifies functional impairments but does not list any acute clinical concerns, medication or 
plan of care changes. The records do not show that skilled nursing services are required in the home setting to 
effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to 
establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. 
 
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 direct skilled nursing services of a registered nurse (RN) in the home health or 
hospice setting, each 15 minutes (G0299).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the parenteral nutritional supplies billed for dates of service 
April 7, 2023, to April 12, 2023. 
 You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the records did not include a physician's order. 
 
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 the rules. The claim submitted shows that the services at issue were provided on April 
7, 10, and 12, 2023. The records provided do not have dates that coincide with the billed dates of service. 
Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the parenteral nutritional supplies billed for dates of service April 
7, 2023, to April 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services rendered on December 11, 2022. 
 
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 claim was denied appropriately per Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that emergency room services are only covered if the 
emergency clinic is affiliated with a hospital. 
 
The rendering free-standing emergency room in this case does not appear to be affiliated with a hospital. 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 emergency room services rendered on December 11, 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 enrollee would like to go back to living 
independently. The Plan denied your request. The Plan says 1012543148  
 
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. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies. 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93355 billed for date of service May 2, 2023.  
 
You asked the Plan to pay for procedure code 93355. You say that the claim was not processed correctly. The 
Plan denied your request. The Plan says payment for code 93355 is bundled into payment for code 00560. 
 
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 93355 
is a column II code to column I code 00560 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 93355 billed for date of service May 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 29, 2023. 
 
You asked the Plan to pay for the lab services. You say that medical records were provided. The Plan denied 
your request. The Plan says an incorrect place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on March 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 8, 2023, billed with 
codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335, 81479, and 81238. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 Review of the file shows that the Plan uses Local Coverage Article (LCA) A57910 to support their denial. 
However, LCA A57910 is not valid for the provider's head quarter state of Florida. Therefore, we are unable to 
use LCA A57910 to substantiate our decision. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
February 8, 2023, billed with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 
81335, 81479, and 81238.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L1 kyphoplasty. 
 
You asked the Plan to pre-approve L1 kyphoplasty. You say that this is medically necessary. The Plan denied 
your request. The Plan says medical necessity coverage criteria is not met as the pain is multifactorial with 
multilevel disc disease. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be 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 L1 kyphoplasty. Our reviewer says that 
the enrollee does not meet criteria for coverage. Our physician reviewer found there is no trial of bracing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L1 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L1 kyphoplasty.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 24, 2022, to 
March 29, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that J15.6 is 
supported in the documentation therefore the claim should be paid at the DRG originally billed. The Plan 
denied your request. The Plan says J15.6 is not supported in the documentation. 
 
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 principal diagnosis J15.6, defined as pneumonia due 
to other gram-negative bacteria. 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 at the DRG originally billed. Our reviewer says that principal diagnosis of J15.6 is not 
supported in the documentation. Our physician reviewer found the enrollee presented with a cough, fatigue, 
and runny nose. Their vitals were stable, lungs clear, and they were alert and oriented. There was no sputum 
culture or other evidence describing a gram-negative bacteria causing pneumonia in the documentation. 
 
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 inpatient hospital services provided on March 24, 2022, to March 29, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pa y for lab services (87632, 87633, 0115U, 0202U, 0223U, 0225U) 
provided on January 26, 2023. 
 
You asked the Plan to pa y for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a respiratory pathogen panel test must not be 
unbundled and billed as individual components regardless of the fact that the panel reports multiple individual 
pathogens and/or targets. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were billed for a single panel. Based on 
this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pa y for lab services (87632, 87633, 0115U, 0202U, 0223U, 0225U) 
provided on January 26, 2023.