Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve block. 
 
You asked the Plan to pre-approve the genicular nerve block. The Plan denied your request. The Plan says the 
genicular nerve block is not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the genicular nerve block. Our reviewer 
says that the genicular nerve block is not medically necessary. Our physician reviewer found that the genicular 
nerve block is considered an experimental and investigational 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 the genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the genicular nerve block.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) and core buildup (D2950) for tooth 
#8. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denied dental 
services. The Plan denied your request. The Plan says the denial of authorization is correct, because tooth #8 
does not show large decay requiring replacing a significant amount of the tooth. 
 
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 the dental 
services 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 the dental services. Our reviewer says 
that the crown and core buildup do not meet the criteria for coverage. Our physician reviewer found that the 
documentation indicates that tooth #8 does not exhibit significant coronal breakdown due to caries or fracture 
to warrant a core buildup (D2950) and crown restoration (D2740). 
 
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 the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a crown (D2740) and core buildup (D2950) for tooth #8.
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 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. 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. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is 
not a 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device 
(E0601) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a CPAP device. You say that you have been using a CPAP device for over 
five years and nothing has changed with your health. The Plan denied your request. The Plan says you must use 
network providers to get your medical care and services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a continuous positive airway pressure (CPAP) device (E0601) to be provided by an out-of-network (OON) 
provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 15, 2023, billed with 
procedure code 93312-26-59. 
 You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we have confirmed that code 93312-26-59 is a column II code to column I code 00567; however, 
93312-26-59 was billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found the procedure report does not support 
separate billing for this service. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on May 15, 2023, billed with procedure code 
93312-26-59.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for the skilled nursing facility services billed for dates of service March 19, 
2023, to March 31, 2023. 
 
You asked the Plan to pay for the billed services. You say that the denial is incorrect. The Plan denied your 
request. The Plan says that the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
We looked at the file and the rules. The Plan denied services based on home health care guidelines, referenced 
by chapter 10 of the Medicare Claims Processing Manual. The claim at issue was submitted with type of bill 
code 211, which indicates a skilled nursing facility claim. The billed National Provider Identifier (NPI) 
confirms the provider as a skilled nursing facility. The Plan has not made reasonable and diligent efforts to 
gather and forward to us information regarding their decision to deny your request.  Therefore, we decided that 
the Plan has to pay for the skilled nursing facility services billed for dates of service March 19, 2023, to March 
31, 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services provided from November 17, 
2021, to November 20, 2021. 
 
You asked the Plan to pay for the services provided. You say that you should not be responsible for the bill. 
The Plan denied your request. The Plan says the claim was not submitted timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services provided was not filed until March 10, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the physical therapy services provided from November 17, 2021, 
to November 20, 2021.   Please note, you may not be charged or held liable for more than plan-allowed cost-sharing. If the provider is 
billing you for charges beyond any applicable cost-sharing amounts, please contact the Plan directly.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the power wheelchair purchased on July 25, 2022.  
You asked the Plan to pay for the power wheelchair. You say that the enrollee's wheelchair broke, and they had 
to purchase a new one. You also say that the wheelchair was authorized as a medical necessity. The Plan 
denied your request. The Plan says the documentation requirements have not been met. The Plan also says that 
there is no documentation of irreparable damage to the enrollee's previous power wheelchair. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid physician signed seven element order, physician signed detailed product 
description order, physical/occupational therapy assessment, home assessment, or any documentation what 
mobility limitations significantly impair the enrollee's ability to participate in one or more mobility-related 
activities of daily living (MRADLs) for the supplies provided in this case. Medicare requires specific 
evaluations be done prior to approval of any power wheelchair, and the necessary evaluations for approval of 
any power wheelchair have not been completed. Therefore, we decided that the Plan does not have to pay for 
the power wheelchair purchased on July 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), 
expandable controller (E2377), and footplate extension (K0108). 
 
You asked the Plan to pre-approve an electronic connection, harness, expandable controller, and footplate 
extension. You say that you would like the patient's request to be re-reviewed as they are in desperate need of 
the power wheelchair. The Plan denied your request. The Plan says although there are three approved power 
options on this wheelchair (tilt, recline and elevating leg rests), there is not a medical need to control these 
power options through the joystick. The Plan also says there is no documentation to show why the footplate 
extension is medically needed. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules also say that miscellaneous options, accessories, or replacement parts 
for wheelchairs that do not have a specific HCPCS code and are not included in another code should be coded 
K0108. 
 
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, 
expandable controller, and footplate extension. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has left 
sided weakness from a stroke, but has 5 out of 5 strength in their right upper extremity. The enrollee has 
sufficient strength and function in their upper extremities to manage standard power drives. Our reviewer found 
that the footplate extension is for abducted and large feet but coded as K0108. Our physician reviewer also 
found that the footplate extension has a HCPCS code and may not be coded as K0108. 
 
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, expandable controller, and footplate 
extension have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic 
connection (E2311), harness (E2313), expandable controller (E2377), and footplate extension (K0108).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each x-ray provided on May 11, 2023. 
 
You asked the Plan to waive the copayment for each x-ray. You say that you were told you would only have to 
pay one copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 
copayment for in-network outpatient diagnostic  tests and therapeutic services. 
 
You have been asked to pay a $15 copayment for each x-ray. This item/service falls within the in-network 
outpatient diagnostic  tests and therapeutic services benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. The records show the x-rays were provided by different providers, and the copayment applies to each x-ray. Therefore, we decided that the Plan does not have to waive the 
copayment for each x-ray provided on May 11, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty of the L1 vertebrae (22511, 69990). 
 
You asked the Plan to pre-approve kyphoplasty of the L1 vertebrae. You say that this procedure is appropriate 
and necessary for this enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria 
for coverage of this procedure. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve kyphoplasty of the L1 vertebrae. 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 documentation of a brace for fracture care. Therefore, it cannot 
be confirmed that the enrollee has not responded to non-surgical medical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty of the L1 vertebrae have not been met. Therefore, we decided that 
the Plan does not have to pre-approve kyphoplasty of the L1 vertebrae (22511, 69990).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0110). 
 
You asked the Plan to pre-approve additional transportation trips. You say that you need additional 
transportation for your dialysis appointments three times a week. The Plan denied your request. The Plan says 
additional trips would exceed your benefit 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 50 trips per year.  
 
We looked at your request, the records in the case file, and the rules. The records show that you have used 
forty-eight (48) one-way transportation trips out of the allowed fifty (50) one-way trips approved. Once 50 trips 
are used, the benefit will be exhausted. Based on this information, we decided that the Plans rules for coverage 
of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve 
additional routine transportation trips (A0110).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on May 19, 
2023. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that you are requesting 
reconsideration of the denied claim. 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 the subsequent nursing 
facility care provided on May 19, 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 May 31, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the guidelines support separate payment. The 
Plan denied your request. The Plan says the code is bundled into code G0168. 
 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 code 99283 was billed on the same day as minor procedure code G0168. CPT code 99283 
was not billed with a modifier indicating separate payment is valid in this case. Based on this information, we 
decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 99283 billed for date of service May 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 21, 2023, billed with 
codes 81218, 81162, 81291, & 81292. 
 
You asked the Plan to pay for the genetic testing billed. You say that this service was medically necessary. 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 
April 21, 2023, billed with codes 81218, 81162, 81291, & 81292.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care 
 
You asked the Plan to waive the copayment for SNF. You say that you disagree with the copayment. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $161 
copayment per day for days 1-100 for skilled nursing facility (SNF) care.  
 
You have been asked to pay a $161 copayment per day for days 1-100 for SNF. The total amount you are being 
asked to pay $322 ($161 x 2 days = $322).This item/service falls within the skilled nursing facility (SNF) care 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) 
care
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory and other services related to end-stage renal 
disease (ESRD) provided on May 4, 2023, to May 16, 2023. 
 
You asked the Plan to pay for the ESRD-related services. You say that dialysis was medically necessary for 
this enrollee and is the only treatment for ESRD. The Plan denied your request. The Plan says they have agreed to pay for dialysis services (90999); however, Medicare does not separately pay for ESRD-related laboratory 
testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory and other services related to end-stage renal disease (ESRD) provided 
on May 4, 2023, to May 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on April 3, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your $2,000 annual maximum has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted. Therefore, we decided that the Plan does 
not have to pay for dental services provided on April 3, 2023.