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

 
We decided that the Plan does not have to pay for dental services provided on June 8, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your $2,000 annual maximum 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 your benefit for the requested item or service was exhausted. Therefore, we decided that the Plan does 
not have to pay for dental services provided on June 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory and other services related to end-stage renal 
disease (ESRD) provided on March 2, 2023, to March 28, 2023. 
 
You asked the Plan to pay for the ESRD-related services. You say that dialysis is medically necessary and the 
only available treatment for the enrollee's ESRD. The Plan denied your request. The Plan says they have agreed to pay for the dialysis services (90999); however, Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory and other services related to end-stage renal disease (ESRD) provided 
on March 2, 2023, to March 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 8, 2023, billed with 
procedure code 96401. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 96401 is chemotherapy administration, subcutaneous or 
intramuscular; non-hormonal anti-neoplastic. 
 
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 practitioner services provided. Our reviewer says that documentation does not support the billed code. Our reviewer found that in this case there is a more specific 
procedure code to report for service documented. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on May 8, 2023, billed with procedure code 
96401.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on May 21, 
2023, to May 28, 2023. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the 
copayment. 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 $285 
copayment per day for days 1-5 for inpatient hospital care.  
 
You have been asked to pay a $285 copayment per day for days 1-5 for inpatient hospital care. The total 
amount you are being asked to pay is $1,425 ($285 x 5 days = $1,425). This item/service falls 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 waive the copayment for inpatient 
hospital care provided on May 21, 2023, to May 28, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve services performed by a qualified physical therapist in 
the home health to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve services performed by a qualified physical therapist in the home health. You 
say that you are staying with your son and you need to see a provider close to him. The Plan denied your 
request. The Plan says this is available in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
services performed by a qualified physical therapist in the home health to be provided 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 vascular compression unit (VCU) (E0217). 
 
You asked the Plan to pay for the VCU. You say that the item was medically necessary. The Plan denied your 
request. The Plan says Items that are used for a preventative service or function are excluded from coverage 
under the Medicare Durable Medical Equipment (DME) benefit.  
 The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. If code E0215 or 
E0217 is provided it will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the vascular compression unit (VCU) (E0217).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on April 
30, 2023. 
 
You asked the Plan to pay for the ED services. You say that this was medically necessary. The Plan denied 
your request. The Plan says Medicare payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare. 
However, during the COVID-19-PHE, such providers were allowed to enroll as temporary hospitals and could be paid for services during this period. 
 
We looked at the file and Medicare rules. We find that the provider at issue has not enrolled as a temporary 
hospital as allowed during the PHE. As such, this provider is not eligible for Medicare payment. Therefore, we 
decided that the Plan does not have to pay for the emergency department (ED) services provided on April 30, 
2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (PVA) of the L4 
vertebrae (22514). 
 
You asked the Plan to pre-approve PVA of the L4 vertebrae. You say that the enrollee is in severe pain which 
cannot be managed without the requested procedure. The Plan denied your request. The Plan says the enrollee 
does not meet the criteria for coverage of this procedure. 
 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 PVA of the L4 vertebrae. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no documentation that a back brace was used for fracture care. It cannot 
be confirmed that the enrollees fracture has not responded to non-surgical medical management at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PVA of the L4 vertebrae have not been met. Therefore, we decided that the Plan 
does not have to pre-approve percutaneous vertebral augmentation (PVA) of the L4 vertebrae (22514).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
March 21, 2023, to April 7, 2023. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you would like the services 
to be fully covered. 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 $275 
copayment per day, days 1 to 6 and a $0 copayment per day, days 7 to 90 of inpatient hospital care.  
 
 
 The record shows you have met your maximum out-of-pocket amount during this service. You have been asked 
to pay a total of $1,320 for the inpatient hospital stay. This item/service falls 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 waive the copayment for an inpatient hospital stay 
provided from March 21, 2023, to April 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87799 and 87900 billed for date of service 
April 12, 2023. 
 
You asked the Plan to pay for procedure codes 87799 and 87900. You say that these services were necessary 
and were reported with payable codes. The Plan denied your request. The Plan says these codes are not 
supported in the medical record. 
 
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 87799 is infectious agent detection by nucleic acid (DNA 
or RNA), not otherwise specified; quantification, each organism. The CPT Code Manual definition of code 
87900 is infectious agent drug susceptibility phenotype prediction using regularly updated genotypic 
bioinformatics. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 87799 and 87900. Our reviewer says that 
these codes are not supported in the medical record. Our reviewer found there are no documentation of tests 
which could be reported with codes 87799 and 87900, and there are no laboratory orders to support that these 
were requested for testing. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87799 and 87900 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 87799 and 87900 billed for date of service April 12, 
2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular artery embolization (36246, 36247). 
 
You asked the Plan to pre-approve the genicular artery embolization. You say that this procedure is medically 
necessary for the treatment of the enrollees condition and will provide long lasting pain relief that will 
improve the enrollees life. The Plan denied your request. The Plan says based on the medical literature this 
procedure is considered experimental or investigational and has not been proven to be beneficial for the 
enrollees condition. 
 
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 genicular artery embolization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that this is an experimental/ investigational procedure that is the subject of ongoing clinical trials. Therefore, the request is deemed not medically reasonable and 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 genicular artery embolization have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the genicular artery embolization (36246, 36247).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab testing codes 81207 and G0452 billed for date of service May 3, 
2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says that the 
documentation does not support the services. 
 
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. 
 
We looked at the file and the rules. For code 81207, this is a valid molecular pathology procedure code. The 
Local Coverage Article, A56199, for the Billing and Coding of Molecular Pathology Procedures states that 
when there is not a code for a panel, use code 81479. The Plan has not shown that a panel without an existing 
panel code was provided. The Plan has not shown that panel testing was billed with more than 1 CPT code. The 
Plan has not provided medical documentation to show that code 81207 was billed incorrectly. Furthermore, the 
billing guidelines does not require a unique identifier for either code, 81207 or 81479, in this case. 
 
For code G0452, billed with the -59 modifier, the Plan denied as the code is bundled into code 81207. The Plan 
states that the service was not distinct or independent from other services provided. The file shows that the 
documentation submitted on appeal included medical documents, which were previously submitted. The Plan 
did not provide the medical documentation submitted to show that code G0452 is not separately payable.  
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request.  Therefore, we decided that the Plan has to pay for the lab testing codes 81207 
and G0452 billed for date of service May 3, 2023.  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 adult diapers. 
 
You asked the Plan to pre-approve incontinence supplies. You say that the item should be covered. The Plan 
denied your request. The Plan says this is not a covered item. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve adult diapers.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a standard wheelchair (K0001). 
 
You asked the Plan to pre-approve a standard wheelchair. You say that the item is medically necessary. The 
Plan denied your request. The Plan says the records do not show a mobility limitation that impedes the 
members ability to complete mobility related activities of daily living in the home. The records do not show 
that the mobility limitation cannot be resolved with a cane or walker or that the home supports the use of a 
manual wheelchair. 
 
The Plan must follow Medicare rules. Medicare rules say that a wheelchair may be covered if your mobility 
limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a standard wheelchair have not been met. Specifically, the records submitted indicate you are able 
to ambulate with a walker. Therefore, we decided that the Plan does not have to pre-approve a standard 
wheelchair (K0001).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory and other services related to end-stage renal 
disease (ESRD) provided on March 1, 2023, to March 31, 2023. 
 
You asked the Plan to pay for the ESRD-related services. You say that these services were medically 
necessary, and dialysis is the only appropriate treatment. The Plan denied your request. The Plan says they have agreed to pay for the dialysis services (90999); however, Medicare does not separately pay for ESRD-
related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory and other services related to end-stage renal disease (ESRD) provided 
on March 1, 2023, to March 31, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee currently meets LTACH 
admission. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute 
care and unstable for transfer to LTACH. 
 
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 enrollee is receiving appropriate care in current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate at this time. 
 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: 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 need this care to regain previous level of 
function and mobility. The Plan denied your request. The Plan says your medical condition does not require 
IRF services, and care can be provided in another setting.  
 
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, 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.  
 
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 waive the copayment for an inpatient hospital stay provided from 
April 18, 2023, to April 22, 2023. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were told that your 
stay would be completely covered. 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 $225 
copayment each day for days 1 to 7 and a $0 copayment for additional Medicare-covered days for hospital care 
each time you are admitted.  
 You have been asked to pay a $225 copayment per day, for days 1 to 4 of the inpatient hospital stay. The total 
amount you owe is $900 ($225 copayment x 4 days = $900). You have not been charged for any additional 
days. This item/service falls 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 waive the copayment for an inpatient hospital stay provided from April 18, 2023, to April 22, 2023.