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

 
We decided that the Plan has to pre-approve  periodontal scaling and root planing - four or more teeth per 
quadrant (D4341). 
 
You asked the Plan to pre-approve periodontal scaling and root planing - four or more teeth per quadrant 
(D4341). You say that the scaling and root planning is necessary to remove subgingival microbiota both alive 
microorganisms and dead to prevent further bone loss. You also say that this service is needed due to gingiva 
migration and bone loss. The Plan denied your request. The Plan says that the criteria for scaling and root 
planing 4 or more teeth in each quadrant has not been met.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers periodontal 
scaling and root planing - four or more teeth per quadrant (D4341) when the services are medically necessary 
and reasonable. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve periodontal scaling and root planing - 
four or more teeth per quadrant (D4341). Our reviewer says that periodontal scaling and root planing of four or 
more teeth per quadrant is medically reasonable and necessary to treat the member's periodontal disease. Our 
physician reviewer found Our physician reviewer also found that a review of the provided documentation 
indicates the presence of periodontal pockets of 5 millimeter of four or more teeth per quadrant with calculus 
accumulation, bleeding with probing and areas of bone loss. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of periodontal scaling and root planing - four or more teeth per quadrant (D4341) 
have been met. Therefore, we decided that the Plan has to pre-approve  periodontal scaling and root planing - 
four or more teeth per quadrant (D4341).  
 
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: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the trifocal lens (V2300) and progressive lens (V2781). We decided 
that the Plan does not have to pay for the polycarbonate lens (V2784), antireflective lens (V2750), and vision 
services (V2799).  
 
You asked the Plan to pay for the trifocal lens (V2300), progressive lens (V2781), polycarbonate lens (V2784), 
antireflective lens (V2750), and vision services (V2799), provided on March 10, 2023. You say that the items 
should be covered. The Plan says that these items are not covered. 
 
We decided that the Plan has to pay for the trifocal lens (V2300) and progressive lens (V2781).  
 
Medicare Rules state that one pair of eyeglasses or contact lenses are covered after cataract surgery. 
 
There are no rules that specify that the glasses would have to be purchased immediately following the surgery 
and the Plan hasnt given any explanation for why theyre not covered. Therefore, we decided that the Plan has 
to pay for the trifocal lens (V2300) and progressive lens (V2781) under the medical benefit.  
 
We also decided that the Plan does not have to pay for the polycarbonate lens (V2784), antireflective lens 
(V2750), and vision services (V2799), provided on March 10, 2023. 
 
Medicare rules state that V2784 and V2750 require a modifier and documentation of medical necessity. 
 
This claim was submitted without the required modifiers and did not include documentation of medical 
necessity for these items. Therefore, we decided that the Plan does not have to pay for the polycarbonate lens 
(V2784), antireflective lens (V2750), and vision services (V2799), provided on March 10, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 87150, 87481, 
87500, 87641, 87653, 87798, and 87801 for date of service March 31, 2023. 
 
You asked the Plan to pay for the laboratory services billed with codes 87150, 87481, 87500, 87641, 87653, 
87798, and 87801. 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 a panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets. 
 
 
 We looked at the file and Medicare rules. Review of the file shows that the services at issue were a panel that 
was billed with individual procedure codes. The services billed should be billed with one procedure code for 
the entire panel. Based on this information, we decided that Medicare rules for coverage of the laboratory 
services billed with codes 87150, 87481, 87500, 87641, 87653, 87798, and 87801 have not been met. 
Therefore, we decided that the Plan does not have to pay for the laboratory services billed with codes 87150, 
87481, 87500, 87641, 87653, 87798, and 87801 for date of service March 31, 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 you are requesting reconsideration of denied 
authorization. The Plan denied your request. The Plan says the coverage criteria has not been met.  
 
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 treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical records support 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. There is no reasonable expectation that this enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for psychotherapy provided from March 10, 2023, to 
July 1, 2023. 
 
You asked the Plan to reimburse you for psychotherapy. You say that the services were medically necessary. 
The Plan denied your request. The Plan says this provider does not participate in the Medicare program and is 
not a Medicare-certified provider.  
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to reimburse you for psychotherapy provided from 
March 10, 2023, to July 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 22 or more drug 
classes (G0483) provided on May 24, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory testing. You say that the testing was medically necessary and have 
submitted medical documentation to support.  The Plan denied your request. The Plan says enrollees must 
receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered. Under Medicare rules, the number of definitive urine drug classes requested are not medically 
necessary. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 22 or 
more drug classes (G0483) provided on May 24, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided on March 27, 2023, billed 
with codes 87150, 87481, 87641, 87653, 87798 and 87801. 
 
You asked the Plan to pay for the laboratory testing billed. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says panel testing should be billed using one HCPCS/CPT 
code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if a laboratory procedure produces multiple reportable 
test results, only a single HCPCS/CPT code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. This was a panel test that was not billed with a single panel code as 
required. Based on this information, we decided that Medicare rules for coverage of the laboratory testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory testing 
provided on March 27, 2023, billed with codes 87150, 87481, 87641, 87653, 87798 and 87801.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on December 26, 2022, 
to December 31, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
diagnosis codes A41.9 (sepsis) and R65.20 (severe sepsis) were accurately reported and billed with the 
appropriate DRG. The Plan denied your request. The Plan says that the medical records did not have sufficient 
documentation to clinically validate the diagnosis of sepsis. Therefore, diagnosis codes A41.9 and R65.20 are 
not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with A41.9 Sepsis, unspecified organism and R65.20 
Severe sepsis without septic shock. 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 inpatient 
hospital services at the DRG originally billed. Our physician reviewer found that the patient did not meet 
Sepsis 3 criteria as there was insufficient evidence to support, she was experiencing a dysregulated response to 
systemic infection leading to organ failure. The hypoxia reported was not confirmed by arterial blood gas and 
was expected considering her diagnosis of chronic obstructive pulmonary disease (COPD) and pneumonia and 
would not indicate organ failure. Therefore, codes A41.9 (sepsis) and R65.20 (severe sepsis) are not supported 
in the documentation   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on December 26, 2022, to December 31, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with multiple 
power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0861) and 
additional items and accessories (codes E0953, E0955, E0956, E0960, E1007, E1012, E1028, E1029, E2311, 
E2313, E2363, E2377, E2620, E2624, and K0108). 
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that the DME is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not have medical need for multiple 
power options included with K0861 group 3 power wheelchair. The Plan also says the electronic connection, 
harness, and expandable controller cannot be covered as it is not medically necessary to control the three 
requested power options through the joystick (drive interface). 
 
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 durable medical equipment (DME). 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee does not have high risk for skin breakdown, use a catheter 
intermittently, have spasticity or require an alternative means of managing power drive. 
 
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 durable medical equipment (DME) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with multiple power 
option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0861) and additional 
items and accessories (codes E0953, E0955, E0956, E0960, E1007, E1012, E1028, E1029, E2311, E2313, 
E2363, E2377, E2620, E2624, and K0108).
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 the enrollee is medically appropriate for 
an LTACH level of care, requiring more intensive skilled respiratory services. The Plan denied your request. 
The Plan says the enrollee does not meet Medicare guidelines for an LTACH admission.  
 
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 are no services available at the LTACH that the enrollee requires that are 
not available at the health care setting being offered by the Plan. Given there are offered alternatives, LTACH 
services are not medically 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 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 laboratory services (88321) provided on December 21, 2022. 
 
You asked the Plan to pay for laboratory services. You say that the services at issue were a medical necessity 
for the enrollee. The Plan denied your request. The Plan says an Explanation of Benefits (EOB) by the primary 
insurer for the services at issue has not been provided. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for laboratory services until the primary insurer has denied the claim for these services. Therefore, we decided 
that the Plan does not have to pay for laboratory services (88321) provided on December 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463), 
electrocardiogram (93005), and lipid panel (80061) provided on July 12, 2022, by an out-of-network (OON) 
provider.  
 
You asked the Plan to pay for the outpatient services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says prior authorization was obtained. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the hospital outpatient clinic visit (G0463), electrocardiogram (93005), and lipid 
panel (80061) provided on July 12, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on May 25, 2023. 
 
You asked the Plan to pay for a home visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a home visit provided on 
May 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing billed with codes 87841, 87801, 87653, and 
87798 for date of service March 17, 2023. 
 
You asked the Plan to pay for the testing. 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 a panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets. 
 
We looked at the file and Medicare rules. Review of the file shows that the services at issue were a panel that 
was billed with individual procedure codes. The services billed should be billed with one procedure code for 
the entire panel. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the testing billed with codes 87841, 
87801, 87653, and 87798 for date of service March 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 87150, 87481, 
87641, 87653, 87798, and 87801 for date of service March 28, 2023. 
 
You asked the Plan to pay for the laboratory services billed with codes 87150, 87481, 87641, 87653, 87798, 
and 87801. 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 a panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets. 
 
 
 We looked at the file and Medicare rules. Review of the file shows that the services provided were billed 
individually. The panel provided should be billed with one procedure code for the entire panel. Based on this 
information, we decided that Medicare rules for coverage of the laboratory services billed with codes 87150, 
87481, 87641, 87653, 87798, and 87801 have not been met. Therefore, we decided that the Plan does not have 
to pay for the laboratory services billed with codes 87150, 87481, 87641, 87653, 87798, and 87801 for date of 
service March 28, 2023.