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

 
We decided that the Plan does not have to pre-approve the Vertiflex device insertion. 
 
You asked the Plan to pre-approve the Vertiflex device insertion. You say that the enrollee has failed multiple 
conservation treatments and the procedure is medically necessary. The Plan denied your request. The Plan says 
the Vertiflex device is not medically necessary. 
 
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 Vertiflex device insertion. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the Vertiflex device is considered experimental. 
 
  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 Vertiflex device insertion have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Vertiflex device insertion.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fixed bridge (pontics and retainer crowns) for teeth 5-
14. 
 
You asked the Plan to pre-approve the requested fixed bridge. You say that it is felt that this should be 
approved. The Plan denied your request. The Plan says the requested fixed bridge is beyond the scope of the 
dental benefit.  
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the requested 
fixed bridge when the services meet the coverage criteria.  
 
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 fixed bridge. Our 
reviewer says that the criteria for the requested fixed bridge are not met. Our physician reviewer found fixed 
bridges are considered when replacing a single maxillary anterior tooth or two adjacent mandibular anterior 
teeth when there are no missing posterior teeth in the arch. In this case, multiple posterior and anterior teeth are 
being replaced. As such, the requested fixed bridge is not covered under the dental benefit. 
 
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 requested fixed bridge have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a fixed bridge (pontics and retainer crowns) for teeth 5-14.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on November 12, 2022. 
 You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider 
processing this claim. The Plan denied your request. The Plan says the NOA was not received timely. As such, 
this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is October 7, 2022. The NOA was not received by the Plan until November 
30, 2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
on November 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and a prefabricated post 
and core (D2954) for tooth #13 provided on May 9, 2023. 
 
You asked the Plan to pay for the dental services. You say that you should have a $4,000 dental benefit 
maximum so the Plan should cover more. The Plan denied your request. The Plan says your annual dental 
maximum benefit for the year has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid $406 for dental services on January 11, 2023. On March 30, 2023, the Plan paid $79 for 
dental services. On April 19, 2023, the Plan paid $772.72 for dental services. On May 9, 2023, the Plan paid 
$742.28 for dental services. For the year of 2023 the Plan paid $2,000 ($406 paid + $79 paid + $772.72 paid + 
$742.28 paid) for dental services; therefore, your annual dental maximum benefit for the year of 2023 was 
exhausted on the date of service of May 9, 2023. Therefore, we decided that the Plan does not have to pay for a 
limited oral evaluation (D0140) and a prefabricated post and core (D2954) for tooth #13 provided on May 9, 
2023.
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 
May 3, 2023.  
 
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 May 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88304 billed for date of service March 16, 
2023. 
 You asked the Plan to pay for procedure code 88304. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 88304 is bundled into payment for code 17311. 
 
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 88304 
is a column II code to column I code 17311. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 88304 billed for date of service March 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS heart failure (HF) system (33289). 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that you have heart failure at 30%. The 
doctor states the procedure is approved by the Food and Drug Administration (FDA) and it should be approved 
by the Plan. The Plan denied your request. The Plan says there is not enough medical proof to show the safety 
and/or success for heart failure monitoring. It is considered experimental and/or unproven and it not covered by 
the plan. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the CardioMEMS device was approved by the FDA in 2014 and consists of a sensor 
device placed in the pulmonary artery to allow measurement of pulmonary artery pressure in the management 
of patients with CHF. The clinical study on which FDA approval was based showed improved clinical 
outcomes and decreased hospitalizations in patients in whom the CardioMEMS system was implanted, 
reflecting a patient population with preserved ejection fraction and was somewhat limited in scope. Subsequent 
follow-up studies remain encouraging and suggest an improvement in heart failure symptoms with the use of 
the device. In addition, published expert opinion in the cardiology literature is supportive of the clinical 
usefulness of CardioMEMS. Nonetheless, there remains a dearth of randomized, blinded clinical studies 
examining long-term clinical outcomes establishing the value of CardioMEMS in patient management. As a 
result, at this time the CardioMEMS system would not be considered medically appropriate and necessary in 
your clinical management. 
 
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 CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS heart failure (HF) system (33289).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the services (99219) provided on October 7, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this procedure has 
been billed and allowed the maximum number of times allowed by our payment policy. 
 
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. The Plan argues that this procedure has been billed and allowed the maximum 
number of times allowed by its payment policy. However, the Plan has not provided documentation showing 
that this service has a maximum allowable, nor has it shown that this service was billed more than once. 
Without supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the 
Plan has to pay for the services (99219) provided on October 7, 2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99309 billed for date of service November 
23, 2022. 
 
You asked the Plan to pay for procedure code 99309. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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, the CPT Code Manual definition of code 99309 is: Subsequent nursing facility care, per day, for 
the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient has developed a significant complication or a significant new problem. Typically, 25 minutes are spent at the 
bedside and on the patient's facility floor or unit. 
 
We find that CPT code 99309 is not supported in the case record. Specifically, the code at issue has been 
reported with Place of Service (POS) code 11, indicating an office setting. The case record does not support 
that services were provided in an office setting. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99309 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99309 billed for date of service November 23, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0157, G0299, Q5002) provided on 
November 26, 2022 to December 5, 2022. 
 
You asked the Plan to pay for the home health 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 providers must report services correctly. 
Providers must report services with the appropriate codes. 
 
We find that codes G0157, G0299, & Q5002 are not supported in the medical record. Specifically, a valid Q & 
G code were not billed on the claim for the dates of service. Based on this information, we decided that 
Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan 
does not have to pay for home health services (G0157, G0299, Q5002) provided on November 26, 2022 to 
December 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 18, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory services. You say that kindly reconsider and process the claim 
towards payment. The Plan denied your request. The Plan says enrollees must receive their medical services 
from an in-network provider with the exception being urgent or emergent services. Non-emergent services with 
non-contracted providers require prior authorization before services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on April 18, 
2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (DME) provided on March 
17, 2023. 
 
You asked the Plan to pay for the DME. The Plan denied your request. The Plan says the documentation 
requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 The record does not contain a valid proof of delivery for the supplies provided in this case. 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 durable medical equipment (DME) provided on March 17, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the commode chair with fixed arms provided on April 6, 
2023. 
 
You asked the Plan to pay for the commode chair with fixed arms. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the item rendered is not a covered benefit. 
 The Plan must follow Medicare rules. The rules say that a commode chair is covered when billed with the KX 
modifier. 
 
Review of the file does not support that the KX modifier was billed on the claim. Without this modifier, the 
claim cannot be paid as billed. Therefore, we decided that the Plan does not have to pay for the commode chair 
with fixed arms provided on April 6, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code J1817 for date of service January 25, 2023. 
 
You asked the Plan to pay for code J1817. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services billed are not supported. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
In this case, the CPT Code Manual definition of code J1817 is insulin for administration through durable 
medical equipment (i.e., insulin pump) per 50 units. 
 
We find that Healthcare Common Procedure Coding System (HCPCS) code J1817 is not supported in the 
medical record. Specifically, the documentation shows that Nova R was administered via intravenous 
treatment. There is a more appropriate code to be billed for the services rendered. Based on this information, 
we decided that Medicare rules for coverage of code J1817 have not been met. Therefore, we decided that the 
Plan does not have to pay for code J1817 for date of service January 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on February 24, 2023, by 
an OON provider.  
 
You asked the Plan to pay for the wound care supplies. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says the supplies were not authorized. 
 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the wound care supplies provided on February 24, 
2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service March 26, 
2023, to April 22, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were medically necessary and 
were ordered by an in-network provider. The Plan denied your request. The Plan says the billed code is invalid 
for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service March 26, 2023, to April 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided from February 27, 2023, to 
February 28, 2023. 
 
You asked the Plan to pay for the medical services. You say that this claim should not have denied due to a 
global surgery issue. The Plan denied your request. The Plan says you billed the incorrect POS code on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must bill the appropriate POS code for 
services.  POS code 21 indicates that the services were performed in an inpatient hospital setting. POS code 22 
indicates that the services were performed in an outpatient hospital setting. 
 
In this case, you billed the claim for these services with POS code 21.  However, the documentation shows that 
the patient was in an observation status.  Observation is an outpatient status, so POS code 22 should have been 
used on the claim instead.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for medical services provided from February 27, 2023, to February 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit rendered on January 24, 2023. 
 
You asked the Plan to pay for the serivces. You say that this should be paid for. The Plan denied your request. 
The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that G89.29 has an Excludes1 note in relation to G89.3. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the serivces have not been met. Therefore, we decided that the Plan does not have to pay for an 
office visit rendered on January 24, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital care and services provided from December 15, 2022, 
to December 20, 2022. 
 
You asked the Plan to pay for inpatient hospital care and services. You say that you have billed the services at 
issue correctly. The Plan denied your request. The Plan says that the services at issue have been billed with an 
incorrect type of bill (TOB). 
 
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 has indicated what the original TOB code was nor what 
the correct TOB code would be. It is the Plan's responsibility to support its denial with evidence. In this case, 
the Plan has not supported its denial, so we must find in your favor. Therefore, we decided that the Plan has to 
pay for inpatient hospital care and services provided from December 15, 2022, to December 20, 2022.  
 
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.