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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you are currently hospitalized, but requires rehab in 
a facility. The Plan denied your request. The Plan says you do does not meet SNF criteria. Your needs can be 
met at a lower level of care with home health services. 
 
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 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 skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 87500. We decided that the 
Plan does not have to pay for the services described by procedure code(s) 87324 and 87150.  
 
You asked the Plan to pay for procedure codes 87324, 87500 and 87150 billed for date of service February 11, 
2023. You say that these services are supported in the medical record. The Plan says that the payment for codes 
87324, 87500 and 87150 is included in the payment for codes 87506, 87500 and 87500 respectively. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 87500.  
 
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 Plans argument for denial of code 87500 is that the payment 
for this code is included in the payment for code 87500. This is not a valid argument. The Plan has provided no 
other reason to explain the denial of code 87500, and this service is not included in any other code billed. 
Therefore, we decided that the Plan has to pay for the services described by procedure code(s) 87500.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 87324 
and 87150. 
 
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 87324 and 87150 are column II codes to column I codes 87506 and 
87500, respectively. However, both codes 87324 and 87150 were 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 the services described by procedure code(s) 87324 and 
87150. Our reviewer says that modifier XU is not supported with these codes. Our physician reviewer found 
the codes in question are not separately identifiable and are therefore included in the approved procedures. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services described by procedure code(s) 87324 and 87150 have not been met. Therefore, we decided that the Plan does not have to pay for the services described by procedure code(s) 
87324 and 87150. 
 
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: DME/ Orthotics
Decision: Favorable

 We decided that the Plan has to pre-approve All lower extremity prostheses, flex-walk system or equal 
(L5981). 
 
You asked the Plan to pre-approve the prosthesis. You say that please reconsider the foot for this enrollee. The 
Plan denied your request. The Plan says that this foot has a maximum weight of 275 pounds and the enrollee 
weighs 281 pounds. This exceeds the safety capacity for the requested foot. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 prosthesis. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found not only does the medical record satisfy Medicare policy in demonstrating this enrollee 
qualifies for the requested foot as a K3 ambulator, but the Plan also attempts to create a more restrictive policy 
for defining K3 function than Medicare policy would allow. The certified prosthetist/orthotist note from April, 
with general corroboration from the prescriber, satisfies Medicare requirements for documenting the enrollees 
K3 function as well as the need for the new prosthesis and foot in question, given its being both out of warranty 
and no longer properly rated for the enrollees weight.  This can be addressed by any number of feet described 
as L5981 if properly ordered from the manufacturer. 
 
LCD L33787 states flex foot system (L5981) is covered for beneficiaries whose functional level is 3 or 
above. No further specific documentation is actually required in the LCD, the Policy Article, or any of the 
relevant Medicare manuals because Medicares policy recognizes that flex-walk feet are part of the basic 
standard of care for all community K3 amputee ambulators given that the evidence of their benefits and 
superiority to less sophisticated alternatives are so well proven and long standing. There is simply no doubt that 
original Medicare would cover a L5981 foot for this K3 level Beneficiary. Therefore, L5981 is hereby 
approved. 
 
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 prosthesis have been met. Therefore, we decided that the Plan has to pre-
approve All lower extremity prostheses, flex-walk system or equal (L5981).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power tilt feature for a power wheelchair. 
 
You asked the Plan to pre-approve power tilt. You say that power tilt is necessary for the enrollee to perform 
pressure relief independently. The Plan denied your request. The Plan says the enrollee does not meet criteria 
for this component. 
 
The Plan follows Medicare rules. Medicare rules state that a power tilt feature may be covered if certain 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 power tilt. Our reviewer says that the 
enrollee does not meet criteria for a power tilt feature. Our physician reviewer found the enrollee does not have 
a high risk for skin breakdown, use an intermittent catheter, or have spasticity impacting positioning. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of power tilt have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a power tilt feature for a power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids provided on March 17, 2023. 
 
You asked the Plan to pay for the hearing aids. You say that the provider was listed on the Plan's website as in-
network. You say the Plan's website did not direct you to the correct hearing unit.  The Plan denied your 
request. The Plan says the service was not a covered benefit. 
 
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 plan's coverage rules apply in this case. The Plan pays for 
hearing aids only received by a Plan Hearing provider. 
 
We looked the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage 
of the hearing aids have not been met. Specifically, the hearing aids were provided by an out-of-network 
provider. Therefore, we decided that the Plan does not have to pay for the hearing aids provided on March 17, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for these services. guided tissue regeneration and bone 
replacement graft (D4266, D7953) provided on January 11, 2023. 
 
You asked the Plan to pay for these services. 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 your benefit for the requested item or 
service 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on the appealed claim. Therefore, we 
decided that the Plan does not have to pay for these services. guided tissue regeneration and bone replacement 
graft (D4266, D7953) provided on January 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the topical application of fluoride (D1206) provided on July 
5, 2022, to November 30, 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 services denied correctly as they do not fall 
within your dental 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. 
 
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, regardless of the providers network status. Therefore, we decided that 
the Plan does not have to pay for the topical application of fluoride (D1206) provided on July 5, 2022, to 
November 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for the inpatient hospital stays provided from 
February 21, 2023, to March 4, 2023. 
 
You asked the Plan to reduce the cost share for the inpatient hospital stays. You say that these charges are too 
high. 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 $375 
copayment per day for days 1-4 of each inpatient hospital stay. Your contract with the Plan also clearly says 
that you then pay a $0 copayment per day for any additional days of the same inpatient hospital stay. 
 
You have been asked to pay a $375 copayment per day for days 1-4 of the inpatient hospital stay provided from 
February 21, 2023, to February 24, 2023. You have been asked to pay a total of $1,500 for this inpatient 
hospital stay ($375 copayment per day x 4 days = $1,500). You have also been asked to pay a $375 copayment 
for day one of the inpatient hospital stay provided on March 3, 2023. You have also been asked to pay a $375 
copayment for day one of the inpatient hospital provided on March 4, 2023. These items/services fall within the 
inpatient hospital care 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 reduce the cost share for the inpatient 
hospital stays provided from February 21, 2023, to March 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam computed tomography (CT) Scan and pulp 
vitality tests (D0364, D0460) provided on March 29, 2023. 
 
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 services denied correctly as they do not fall 
within your dental 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. 
 
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, regardless of the providers network status. Therefore, we decided that 
the Plan does not have to pay for a cone beam computed tomography (CT) Scan and pulp vitality tests (D0364, 
D0460) provided on March 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture  resin base (including, 
retentive/clasping materials, rests, and teeth) (D5212). 
 
You asked the Plan to pre-approve the mandibular partial denture  resin base and maxillary partial denture. 
You say that the service was ordered for medical necessity and at the moment you are in a dental restoration 
process where you received bone graft. You also say that the x-rays can be provided by the dental provider, 
The Plan denied your request. The Plan says the correct code for implant-supported removable partial denture 
(which is the treatment needed) is D6113 implant-supported removable prosthesis for partially edentulous arch 
- mandibular. 
 
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 
mandibular partial denture  resin base 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 mandibular partial denture  resin 
base. Our reviewer says that the  mandibular partial denture  resin base is not medically necessary. Our 
physician reviewer found you have two implant abutments in the areas of tooth #'s 22 and 27. The coding for 
an appropriate appliance should be reconsidered to match the existing clinical situation. The requested partial 
denture code is not the appropriate code to use where there are no natural teeth present. An implant supported 
overdenture is the appropriate code under D6111, as there are no natural teeth in the arch. The claim must be 
resubmitted with proper coding. 
 
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 mandibular partial denture  resin base have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a mandibular partial denture  resin base (including, 
retentive/clasping materials, rests, and teeth) (D5212).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve a continuous glucose monitor. You say that this item is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced 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 a continuous glucose monitor. Our reviewer says that the requested device is not medically necessary. Our physician reviewer found the record indicates that the enrollee has diabetes. The record provided does not indicate that the enrollee is being treated with insulin or has problematic hypoglycemia.

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 continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95861 and 95865 billed for date of service 
June 16, 2022.  
 
You asked the Plan to pay for procedure codes 95861 and 95865. You say that you have billed the services at 
issue correctly. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT codes 95861 and 95865 is 1. The MAI value for these codes is 3. You billed 2 
units of each of these codes, exceeding the MUE. You did not provide all the required evidence showing that 
the excess units were actually provided, were correctly coded, and were medically necessary. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 95861 and 95865 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 95861 and 95865 billed for 
date of service June 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the bone replacement graft (D4263) and guided tissue 
regeneration (D4266) provided on February 21, 2023. 
 
You asked the Plan to pay for the dental services. You say that these procedures should be covered. The Plan 
denied your request. The Plan says your benefit for the requested item or service 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 21, 2023. When 
the Plan reprocessed claim 202302246687397 exhausting your $2,500 annual allowance for dental services. 
Therefore, we decided that the Plan does not have to pay more for the bone replacement graft (D4263) and 
guided tissue regeneration (D4266) provided on February 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the drugs or medicaments dispensed in the office for 
home use (D9630). 
 
You asked the Plan to pre-approve the  dental services represented by codes D9945, D2740, D4910, D3330, 
D3910, D2950 and D9630. You say that  the x-rays were required because after reviewing it was determined 
that upper and bottom teeth required dental work.  

You are also asking to reconsider and allow payment as there is evidence that indicates the necessary measures 
are needed to provide immediate medical attention. The Plan denied your request. The Plan says there is no 
coverage for other drugs and /or medicaments by report. 
 
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 drugs or medicaments dispensed in 
the office for home use is not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pre-approve the drugs or medicaments dispensed in the office for home use (D9630).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an adjunctive pre-diagnostic test, topical application of 
fluoride varnish, and gingival irrigation services (D0431, D1206, D4921) provided on March 21, 2023. 
 
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 services denied correctly as they do not fall 
within your dental 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. 
 
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 pay for an 
adjunctive pre-diagnostic test, topical application of fluoride varnish, and gingival irrigation services (D0431, 
D1206, D4921) provided on March 21, 2023.