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 the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
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 enrollee did not require any skilled nursing or rehabilitation services on a daily 
basis at an inpatient level of care. The enrollee was not expected to make measurable gains within a reasonable 
and predictable period of time or require skilled therapy to prevent deterioration with mobility or self-care 
tasks. The enrollee did not require skilled therapy to establish a safe and effective maintenance program. As a 
practical matter, the enrollee did not require any skilled services on an inpatient basis, at a SNF level of care at 
the time of discharge from the hospital. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you hope someone, or all involved in this 
process will understand the severity of lack of help those questions on the new attestation form are causing, the 
lack of help you have been denied, and your status be returned to where it should be, The Plan denied your 
request. The Plan says the criteria for eligibility have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you have been in the hospital since last year 
due to illness. You also say that a new doctor completed the online form and does not have your hospital 
records. The Plan denied your request. The Plan says the criteria for eligibility have not been met. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tetanus, diphtheria toxoids and acellular pertussis (Tdap) 
vaccine (90715) and immunization administration (90471) provided on December 1, 2022. 
 
You asked the Plan to pay for the Tdap vaccine and administration. You say that if you had been informed the 
Tdap vaccine was not covered, this treatment would have been rejected. The Plan denied your request. The 
Plan says these services are not covered under Part B, and you have no Part D benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tdap vaccine 
and administration. The Plan follows the same rules.  
 
 
  Records do not show that you have been injured or directly exposed to any illness related to the Tdap vaccine 
and administration. Therefore, we decided that the Plan does not have to pay for the Tetanus, diphtheria toxoids 
and acellular pertussis (Tdap) vaccine (90715) and immunization administration (90471) provided on 
December 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle test strips. 
 
You asked the Plan to pre-approve Freestyle test strips. You say that the requested test strips are medically 
necessary. The Plan denied your request. The Plan says only the preferred brand products listed in the EOC are 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for Freestyle test strips. Therefore, we decided that the Plan does not have to pre-approve Freestyle test strips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 1, 2022, billed 
with codes 81225, 81227, 81230, 81231, 81232, 81240, 81241, 81291, 81335, 81355 and 81408. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary and 
is supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
November 1, 2022, billed with codes 81225, 81227, 81230, 81231, 81232, 81240, 81241, 81291, 81335, 81355 
and 81408.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 1, 2022, billed 
with codes 81227, 81230, 81231, 81232, 81240, 81241, 81291, 81328, 81335, 81355, and 81408. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
November 1, 2022, billed with codes 81227, 81230, 81231, 81232, 81240, 81241, 81291, 81328, 81335, 
81355, and 81408.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 25, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service 
on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on October 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Ottobock Kenevo microprocessor knee, and flex-
walk system. 
 
You asked the Plan to pre-approve a microprocessor knee and flex-walk system. You say that the requested 
prosthetic is medically necessary for the enrollee. The Plan denied your request. The Plan says the requested 
components exceed the enrollee's need. 
 
The Plan follows Medicare rules. Medicare rules say that a microprocessor knee and a flex-walk system or 
equal are covered for beneficiaries whose functional level is 3 or above. 
 
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 microprocessor knee and flex-walk 
system. Our reviewer says that the requested microprocessor knee and flex-walk system are not medically 
necessary. Our physician reviewer found the guidelines indicate the requested components require the enrollee 
to be a K3 ambulator. The reviewer found that the provided documentation does not support that the enrollee is 
able to ambulate at a K3 functional level. The reviewer found there is no clear documentation to support the enrollee requires a microprocessor knee or flex-walk system. Therefore, the reviewer found that the requested 
microprocessor knee and flex-walk system are not medically reasonable or 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 a microprocessor knee and flex-walk system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an Ottobock Kenevo microprocessor knee, and flex-walk 
system.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 1, 2022, billed 
with codes 81227, 81230, 81231, 81232, 81240, 81241, 81291, 81335, 81355 and 81408. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
November 1, 2022, billed with codes 81227, 81230, 81231, 81232, 81240, 81241, 81291, 81335, 81355 and 
81408.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that you disagree with the denial. The 
Plan denied your request. The Plan says you do not meet any of the requirements for an inpatient stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient hospital care is met in this 
case. Our physician reviewer found you were diagnosed with incomplete uterovaginal prolapse with a planned 
elective procedure to treat your condition. This is a request for inpatient services related to this procedure. 
However, the provided documentation did not describe you as unstable or with a high-risk condition or 
expectation that you would require hospital services that would likely cross 2 midnights for this typically 
ambulatory procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 25, 2022. You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service 
on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on October 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition, endoskeletal system, below knee, flexible 
protective outer surface covering system (L5962). 
 
You asked the Plan to pre-approve a protective cover. You say that you need a new leg so that you can walk 
long distance, shop, attend church and do everyday things for long periods of time. Mobility to move around is 
limited. The current leg is suitable for short term walking. The Plan denied your request. The Plan says there is 
no documentation that supports that your activity subjects your prosthesis to harsh environmental situations or 
that you engage in any extraordinary activities that would justify the need for extra protection with a flexible 
outer surface covering system. The cover is not medically necessary and cannot be covered. 
 
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 protective cover. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no information indicating you live or work in harsh conditions. The decision is 
unfavorable. Per L33787, the criteria for an advanced cover L5962 are not present in the physician's notes or 
order. 
 
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 protective cover have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an addition, endoskeletal system, below knee, flexible protective outer surface 
covering system (L5962).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the mileage (S9975) driven on December 15, 2022. 
 
You asked the Plan to pay for the mileage. You say that the services provided on December 15, 2022, were 
transplant care and that the provider is part of the transplant institutes network. The Plan denied your request. 
The Plan says that the provider they contacted saw the enrollee on December 6, 2022, for transplant care, but 
not on December 15, 2022. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not provide us with any medical records or evidence of 
having made reasonable attempts to obtain medical records from the doctor who provided services on 
December 15, 2022. Without this information, we cannot determine whether the services in dispute were in fact 
unrelated to your transplant care. The Plan has not substantiated their denial reason. Therefore, we decided that 
the Plan has to pay for the mileage (S9975) driven on December 15, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement graft for ridge preservation - per site 
(D7953). 
 
You asked the Plan to pre-approve dental services. You say that you are on a limited income, and you would 
like your insurance to cover the requested services. The Plan denied your request. The Plan says this service is 
not covered under your Plan. 
 
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. Bone replacement graft for 
ridge preservation - per site (D7953) is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D7953 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve bone 
replacement graft for ridge preservation - per site (D7953).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for July 13, 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 procedure code 99233 is not supported by the medical records. 
 
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 99233 is subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 50 minutes must be met or exceeded. 
 
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 these services. Our reviewer says that procedure code 99233 
is not supported by the medical records. Our reviewer found the submitted notes describe the enrollee as having 
altered mental status due to opioids that was resolving without complaints. The histories were focused and 
detailed and the physicals were detailed but not comprehensive. There is no documentation of a comprehensive 
history or physical or evidence of medical decision making of high complexity for July 12, 2022 or July 13, 
2022 to support code 99233. 
 
We looked at this coder's review, the file, and Medicare rules. 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 code 99233 billed for July 13, 2022.