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

 
We decided that the Plan has to pre-approve the four crowns (D2740 x4). 
 
You asked the Plan to pre-approve the crowns. You say that the Plan's documentation clearly states that the 
benefits allotted for dental services includes a $0 copay for crowns. You also say that nowhere did it specify 
that the criteria for dental services would not allow for crowns to be installed on teeth that had any wear and 
tear, but only on health teeth, which makes no sense. The Plan denied your request. The Plan says that a pre-
operative x-ray is necessary in order to process this claim. 
 
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 records do not support the Plan's denial in this case. This means that the 
Plan has not provided a valid reason for denying payment of the crowns. There is no documentation showing 
the Plan requested x-rays from the in-network provider decide that the crowns are not medically necessary. It is 
the burden of the Plan to substantiate their denial with evidence. In this case, the denial has not been 
substantiated. Therefore, we decided that the Plan has to pre-approve the four crowns (D2740 x4).  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services for date of service June 28, 2021, to 
July 22, 2021. 
 
You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that the claims information and OASIS data elements 
are used to group 30-day periods of care into their case-mix groups. 
 
 
 We looked at the file and Medicare rules. Review of the file shows that the documentation submitted did not 
include OASIS comprehensive assessment and visit notes for the billed 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 the home health services for date of service June 
28, 2021, to July 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 95861 billed for date of service August 1, 
2022.  
 
You asked the Plan to pay for procedure code 95861. You say that you disagree with the denial. 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 code 95861 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, 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 code 95861 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 95861 billed for date of service August 1, 2022.
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 services are medically necessary for 
the enrollee's complex medical needs. The Plan denied your request. The Plan says the enrollee is receiving 
appropriate inpatient acute care and is currently unstable for transfer to an 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 there are no required medical services identified that are available at the LTACH, 
that are not available at the current health care setting being offered by the health plan. The requested LTACH 
services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 
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: 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 need to be assessed both medically and 
functionally in regard to your functional capacity to determine whether you can benefit from a rehabilitation 
level of care offered by mentioned facility.  The Plan denied your request. The Plan says you no longer require 
skilled therapy on a daily basis.  
 
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 the clinical documentation shows that inpatient therapy goals have been met. You 
would not be expected to require continued daily skilled therapy. Clinical documentation does not specify any 
daily skilled nursing needs to support the need for continued daily skilled services.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on November 17, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim for this molecular pathology testing did not include the required unique 
identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on 
November 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99418 and 99233 billed for date of service 
February 3, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says 99418 is invalid for Medicare purposes and 99233 were billed with invalid diagnosis 
codes. 
 
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 99418 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99418 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met.  
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the billed diagnosis codes are mismatched for 
code 99233. Based on this information, we decided that Medicare rules for coverage of these services have not 
been met. 
 
Therefore, we decided that the Plan does not have to pay for procedure codes 99418 and 99233 billed for date 
of service February 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 82671 for date of service March 15, 2023. 
 
You asked the Plan to pay for procedure code 82671. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that an Excludes1 note indicates that the code 
excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used 
when two conditions cannot occur together, such as a congenital form versus an acquired form of the same 
condition. 
 
We looked at the file and Medicare rules. Review of the file shows that code 82671 was billed with diagnosis 
codes E29.1 (Testicular hypofunction) and E23.0 (Hypopituitarism). Since there is an Excludes1 note, these 
two codes should not be billed together. The claim is not payable as billed. Based on this information, we 
decided that Medicare rules for coverage of procedure code 82671 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code 82671 for date of service March 15, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 73030 for date of service February 26, 2023. 
 
You asked the Plan to pay for procedure code 73030. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services were not billed with an anatomic modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that services must be billed with an anatomic 
modifier. 
 
We looked at the file and Medicare rules. Review of the file shows that code 73030 was not billed with an 
anatomic modifier. This code is not payable as billed. Based on this information, we decided that Medicare 
rules for coverage of procedure code 73030 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 73030 for date of service February 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guidance UTI testing provided on March 17, 2023. 
 
You asked the Plan to pay for the Guidance UTI testing. You say that this testing should be covered. The Plan 
denied your request. The Plan says this testing is not covered under Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this 
information, we decided that Medicare rules for coverage of the Guidance UTI testing have not been met. Therefore, we decided that the Plan does not have to pay for the Guidance UTI testing provided on March 17, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88305 billed for date of service February 9, 
2023. 
 You asked the Plan to pay for procedure code 88305. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 88305 is bundled into payment for code 17313. 
 
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 88305 
is a column II code to column I code 17313. 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 88305 billed for date of service February 9, 
2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services for date of service July 28, 2022, to 
August 24, 2022. 
 You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. 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 July 28, 2022. The NOA was not received by the Plan. 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 the home health services for date of service July 
28, 2022, to August 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87481, 87641, 87653) provided on February 21, 
2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says these codes are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 87481, 87641, & 87653 are not supported in the medical record. Specifically, the 
billed codes are included in procedure code 87798 which was also billed. 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 lab services (87481, 87641, 87653) provided on February 21, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is getting weaker and weaker in their 
home and requires more therapy than what they are receiving. 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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require intensive rehabilitation physician or nursing oversight in an IRF. The enrollee's functional 
level does not require treatment by multiple therapies including physical or occupational therapy in an intensive 
rehabilitation program in an IRF. The documentation does not support that the enrollee requires therapy on an 
IRF intensive level.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300) and attendant 
control (E2331). 
 
You asked the Plan to pre-approve a power seat elevation system and attendant control. You say that the 
services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that power wheelchair accessories are covered when 
specific criteria are met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a power seat elevation system and attendant control have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a power seat elevation system (E2300) and attendant control (E2331).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services billed with code 11102 for January 18, 
2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says payment is included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that follow-up services are included in the global surgical 
package. 
 
We looked at the file and Medicare rules. Procedure code 11102 was related to and billed within 90 days of 
major surgical procedure billed with code 14021 on November 7, 2023. Payment for code 11102 is included in 
the global surgical payment for 14021. Therefore, we decided that the Plan does not have to pay for the surgical 
services billed with code 11102 for January 18, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99283 billed for date of service March 12, 
2023. 
 You asked the Plan to pay for procedure code 99283. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 99283 is bundled into payment for code 99285. 
 
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 99283 
is a column II code to column I code 99285. 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 99283 billed for date of service March 12, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 95938-TC, 95927-TC, and 95940 billed 
for date of service May 24, 2022. 
 
You asked the Plan to pay for procedure code(s) 95938-TC, 95927-TC, and 95940. You say that the claim is 
billed correctly and should be paid. The Plan denied your request. The Plan says this code is included in the 
facility payment and is not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 95938-TC, 95927-TC, 
and 95940. This means there is both a professional and technical component for the CPT code(s). In this case, 
an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 95938-
TC, 95927-TC, and 95940. Based on this information, we decided that Medicare rules for coverage of 
procedure code 95938-TC, 95927-TC, and 95940 have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code(s) 95938-TC, 95927-TC, and 95940 billed for date of service May 24, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant surgeon services billed with code 27520-RT-AS 
on June 14, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the assistant surgeon services are not covered. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 27570-RT-AS. The Medicare Fee Schedule Database contains a surgical 
indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not 
medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria 
for these services have not been met. Therefore, we decided that the Plan does not have to pay for the assistant 
surgeon services billed with code 27520-RT-AS on June 14, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes T2005 and T2049 billed for date of service 
February 20, 2023. 
 
You asked the Plan to pay for procedure codes T2005 and T2049. You say that these services were necessary 
and are supported in the medical record. The Plan denied your request. The Plan says the billed codes are 
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 codes T2005 and T2049 have a Status Indicator of I on the Physician Fee Schedule. 
This means that procedure codes T2005 and T2049 are not valid for Medicare purposes. Based on this 
information, we decided that Medicare rules for coverage of procedure codes T2005 and T2049 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes T2005 and T2049 billed for 
date of service February 20, 2023.