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

 
We decided that the Plan does not have to pay for intravenous moderate (conscious) sedation/analgesia- first 15 
minutes (D9239), intravenous moderate (conscious) sedation/analgesia  each subsequent 15 minute increment 
(D9243), deep sedation/general anesthesia  each subsequent 15 minute increment (D9223), extraction, erupted 
tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if 
indicated (D7210) provided on May 25, 2023. 
 
You asked the Plan to pay for the dental services. You say that you thought that you were approved for the loan 
and feel you were misled to believe that all your dental work would be covered.  The Plan denied your request. The Plan says that sedation/anesthesia services are not listed as covered service 
and surgical extractions are listed as an exclusion. 
 
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, 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 
intravenous moderate (conscious) sedation/analgesia- first 15 minutes (D9239), intravenous moderate 
(conscious) sedation/analgesia  each subsequent 15 minute increment (D9243), deep sedation/general 
anesthesia  each subsequent 15 minute increment (D9223), extraction, erupted tooth requiring removal of 
bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided 
on May 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA test (81479) provided on March 14, 2023. 
 
You asked the Plan to pay for the PrismRA test. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says the requested test does not meet requirement for approval. 
 
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. The DEX database shows that PrismRA is not covered. Based on this information, we decided that Medicare rules for coverage of the PrismRA test have not been met. Therefore, 
we decided that the Plan does not have to pay for the PrismRA test (81479) provided on March 14, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the definitive drug testing, 22 or more drug classes (G0483) provided 
April 6, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that please see attached documents as an appeal 
request. The Plan denied your request. The Plan says that under Medicare rules, the number of definitive urine 
drug classes requested are not medically necessary.  
 
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 pay for the laboratory service. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found given the monitoring and concern for non-compliance with pain contract the testing was 
medically reasonable and necessary to determine if appropriate utilization of narcotics. 
 
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 laboratory service have been met. Therefore, we decided that the Plan has to 
pay for the definitive drug testing, 22 or more drug classes (G0483) provided April 6, 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room visit provided on June 7, 2023. 
 
You asked the Plan to pay for 99285. You say that you are appealing with supporting record. The Plan denied 
your request. The Plan says diagnosis code T40.2X1A has a note to code first the adverse effects or nature of 
adverse effects and use additional codes for all manifestations of poisonings. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of decision-making. 
 
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 99285. Our reviewer says that this code is not supported for payment. Our reviewer found when reporting diagnosis code T40.2X1A a guideline exists stating: "Code first, 
for adverse effects, the nature of the adverse effect." In this case, another diagnosis code should be reported 
first. Therefore, the services were reported incorrectly. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99285 have not been met. Therefore, we decided that the Plan does not have to 
pay for an emergency room visit provided on June 7, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, harness, and expandable controller. You say that 
when three or more power seating functions/actuators/motors are provided, one unit of E2311, one unit of 
E2377, and one unit of E2313 are allowed. The Plan denied your request. The Plan says that an electronic 
connection, harness, and expandable controller cannot be covered as they are not medically necessary to 
control the three approved power options through the joystick (drive interface). 
 
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 an electronic connection, harness, and 
expandable controller. Our reviewer says that the requested items/services are considered medically reasonable 
and necessary in this case. Our physician reviewer found the enrollee is non-ambulatory and requires a power 
wheelchair for mobility and performing their basic daily activities. The enrollee cannot functionally perform 
pressure relief independently and requires a power wheelchair with power tilt and recline for adequate pressure 
relief and positioning. The enrollee currently has multiple pressure wounds and requires a wound vacuum. Our 
reviewer found that the enrollee requires power elevating leg rests for positioning of their lower extremities and 
lower extremity spasticity. The complexity of their seating and positioning needs necessitates a more complex 
group 3 power wheelchair base. The expandable controller with harness and electronic connection are 
necessary to operate the group 3 power wheelchair base and the three power options via a joystick. Our 
physician reviewer also found that these components are required to operate 3 or more power options on a 
group 3 power wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection, harness, and expandable controller have been met. 
Therefore, we decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377).  
 
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: 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 admission is medically necessary for the enrollee's 
weakness and spinal stenosis. The Plan denied your request. The Plan says the enrollee's condition does not 
meet all of the requirements for inpatient rehabilitation admission. The Plan says services may be provided at a 
lower level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
 
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 pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from IRF care. The Plan 
denied your request. The Plan says the enrollee's 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 the complexity of the enrollee's medical, rehabilitation, and nursing needs does not 
require IRF care with an interdisciplinary approach to rehabilitative care.The enrollee's rehabilitation needs can 
be safely provided in an alternate setting.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0433, A0425) billed for date of 
service April 9, 2023.  You asked the Plan to pay for ambulance services. You say that this service was medically necessary and 
appropriate. 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 A0433 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. In addition, because we cannot verify 
the base service, we cannot verify the mileage billed with this code. Based on this information, we decided that 
Medicare rules for coverage of procedure code A0433 have not been met. Please note that the record shows 
that one unit of A0433-HH and 9 units of A0425 were paid by the Plan on May 9, 2023. Therefore, we decided 
that the Plan does not have to pay for ambulance services (A0433, A0425) billed for date of service April 9, 
2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (36215, 75710) provided on February 20, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes 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 CPT code. 
 
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. Our reviewer says that the use of codes 36215 
and 75710 is not supported by the records provided. Our reviewer found that codes 36215 and 75710 are 
included in code 36906, and are not separately payable. Additionally, modifier 59 is not supported for code 
36215.  
 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 have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (36215, 75710) provided on February 20, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says admission to the LTACH is not medically 
necessary.  
 
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 that there is no therapeutic advantage in transferring the enrollee to an LTACH 
compared to remaining in the current setting and then transferring to a lower level of care once appropriate.  
 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 LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87798 billed for date of service March 27, 
2023.   
You asked the Plan to pay for procedure code 87798. 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 87798 is 13. The MAI value for this code is 3. You billed 19 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 87798 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 87798 billed for date of service March 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service March 16, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to 1, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 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 81456 
is a column II code to column I code 81455 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Please note that the NCCI 
indicator change that you reference was not officially implemented until October 1, 2023. This date is well 
after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the right to 
submit the claim again for additional consideration based on the rule change. Therefore, we decided that the 
Plan does not have to pay for procedure code 81456 billed for date of service March 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service February 6, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to 1, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 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 81456 
is a column II code to column I code 81455 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Please note that the NCCI 
indicator change that you reference was not officially implemented until October 1, 2023. This date is well 
after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the right to 
submit the claim again for additional consideration based on the rule change. Therefore, we decided that the 
Plan does not have to pay for procedure code 81456 billed for date of service February 6, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transportation exceeding 50-mile benefit. 
 
You asked the Plan to pre-approve transportation.. The Plan denied your request. The Plan says your request 
will exceed your plan benefits limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 88 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve transportation exceeding 50-mile benefit.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  
 
You asked the Plan to pre-approve continued skilled nursing facility services.. The Plan denied your request. 
The Plan says the records show that the enrollee has used/have used 100 days. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from May 26, 2023, 
through September 18, 2023 skilled nursing facility services. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pre-approve
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan. You asked the Plan to pre-approve Hyalgan. 
You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the enrollee must first try or be unable to use the Plan's preferred medications which are Synvisc, Durolane, and 
Gelsyn-3.  
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Hyalgan. Our reviewer says that the 
requested drug is not medically necessary. Our physician reviewer found that the enrollee has not tried and 
failed the required drugs. There is no documentation provided indicating that the Plans required drugs would 
likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalgan.