Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 3, 2023, to 
March 30, 2023, and billed with Health Insurance Prospective Payment System (HIPPS) code 3FC21. 
 
You asked the Plan to pay for home health services. You say that this was billed correctly. The Plan denied 
your request. The Plan says the documents support HIPPS code 3FB21 rather than 3FC21. 
 
The Plan follows Medicare rules. Medicare rules say that in the distinct 5-position, alphanumeric home health 
Health Insurance Prospective Payment System (HIPPS) codes, position 3 indicates the Functional Level with A 
for Low, B for Medium, and C for High. 
 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 home health services. Our reviewer says that 
the billed HIPPS code is not supported. Our physician reviewer found the submitted records do not give an 
accurate description of the functional impairment for the appropriate period of time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pay for home health services provided from March 3, 2023, to March 30, 2023, and billed 
with Health Insurance Prospective Payment System (HIPPS) code 3FC21.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing for prostate cancer (81541). 
 
You asked the Plan to pay for the genetic testing for prostate cancer. You say that this testing is medically 
necessary. The Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that code 81541 is unlikely to impact therapeutic 
decision-making in the clinical management of the enrollee and will be denied automatically as not medically 
necessary. 
 
We looked at the file and Medicare rules. The code at issue is not covered. Therefore, we decided that the Plan 
does not have to pay for the genetic testing for prostate cancer (81541).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service July 12, 
2023.  
 You asked the Plan to pay for procedure code 76641. You say that two units of this code were medically 
necessary. 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 claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with two units instead of billing 
one line item with one unit with the bilateral modifier as is required. Based on this information, we decided that 
Medicare rules for coverage of procedure code 76641 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 76641 billed for date of service July 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prefabricated abutment tooth 14 (D6056) and abutment 
supported porcelain fused to metal crown tooth 14 (D6059). 
 
You asked the Plan to pre-approve prefabricated abutment and abutment supported crown. You say that this is 
medically necessary. The Plan denied your request. The Plan says this request is not medically necessary. This 
can be covered if x-rays sent by your provider show existing implants have fused well with the bone. The 
records sent do now show the implant has fused well with the bone. 
 
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 prefabricated 
abutment and abutment supported crown 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 prefabricated abutment and abutment 
supported crown. Our reviewer says that the service is not medically necessary. Our physician reviewer found 
there were no x-rays or clinical notes included in the documentation. Based on the lack of information 
provided, D6056 (prefabricated abutment-includes modification and placement) and D6059 (abutment 
supported porcelain fused to metal crown (high noble metal)) for tooth #14 is not medically reasonable or 
necessary. These codes in question are used to restore an implant. There is no evidence of implant placement 
for tooth #14 and therefore the requested treatment is not medically reasonable or necessary. 
 
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 prefabricated abutment and abutment supported crown have not been met. 
Therefore, we decided that the Plan does not have to pre-approve prefabricated abutment tooth 14 (D6056) and 
abutment supported porcelain fused to metal crown tooth 14 (D6059).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Ankle foot orthosis (AFO) (L1971) provided on May 24, 
2023. 
 
You asked the Plan to pay for the AFO. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the items denied correctly as the enrollee does not meet the 
clinical requirements to be approved. 
 
The Plan follows Medicare rules. Medicare rules say that the enrollee's medical record must contain sufficient 
documentation of the enrollee's medical condition to substantiate the necessity for the type and quantity of 
items ordered and for the frequency of use or replacement (if applicable). 
 
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 AFO. Our physician reviewer found that 
the medical information does not include duration of the enrollee's condition, clinical course, prognosis, nature 
and extent of functional limitations, and other therapeutic interventions with their results. Therefore, the 
requested left AFO does not meet the Plan's criteria for dispensing and is 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 the AFO have not been met. Therefore, we decided that the Plan does not have 
to pay for Ankle foot orthosis (AFO) (L1971) provided on May 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device (L8702). 
 
You asked the Plan to pre-approve the orthotic device. You say that the enrollee has been referred by their 
physiatrist for myoelectric orthotic restoration, using the MyoPro Motion G. The Plan denied your request. The 
Plan says this is considered experimental and investigational due to insufficient evidence of safety and efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. A myoelectric or power enhanced upper extremity orthotic 
device (L8701, L8702) is not covered as these are considered investigational or unproven for any indication. 
Based on this information, we decided that Medicare rules for coverage of the orthotic device have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device 
(L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a leg reduction kit (non-elastic binder for a leg) 
identified with codes E1399, A9270. 
 You asked the Plan to pre-approve a leg reduction kit. You say that the reduction kit is a needed treatment for 
lymphedema. The Plan denied your request. The Plan says this item does not meet the definition of a surgical 
dressing and is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that non-elastic binder for any extremity is noncovered 
because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve a leg reduction kit 
(non-elastic binder for a leg) identified with codes E1399, A9270.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services should be covered as the 
enrollee disagrees with the denial. The Plan denied your request. The Plan says the services denied correctly as 
the enrollee does not meet the clinical requirements to be approved. 
 
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 the enrollee's needs can be met at a lower level of care. There are no services at 
LTACH which are not available in the enrollee's current setting and thus no therapeutic benefit to transfer. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walker provided on June 28, 2023, by an out-of-network 
(OON) provider.  
 
You asked the Plan to pay for the OON walker. You say that you were told no authorization was required for 
this item.  The Plan denied your request. The Plan says non-emergent OON services must be authorized.  
 
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 walker provided on June 28, 2023, by an out-
of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88304 billed for date of service January 20, 
2023. 
 
You asked the Plan to pay for the billed service. You say that medical records were provided. The Plan denied 
your request. The Plan says an appropriate primary procedure code was not billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 88304 was billed with primary diagnosis code T84.84XS, defined as pain due to 
internal orthopedic prosthetic devices, implants and grafts, sequela. The condition or nature of the sequela is 
sequenced first. The sequela code is sequenced second. Based on this information, we decided that Medicare 
rules for coverage of the billed service have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 88304 billed for date of service January 20, 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 need IRF services, or your health will continue 
to decline. The Plan denied your request. The Plan says you do not meet the requirements for an IRF 
admission.  
 
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 your nursing, medical, and rehabilitation needs does not require an 
acute hospital inpatient stay, with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. There is not a reasonable expectation 
that you will be able to fully participate in and benefit from the intensive rehabilitation program provided in an 
IRF. Medically necessary care can be provided in a different level of 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital bed provided on June 10, 2023. 
 
You asked the Plan to pay for the hospital bed. You say that you billed with a valid diagnosis. The Plan denied 
your request. The Plan says the diagnosis code at issue is not appropriate as a primary diagnosis.  
The Plan must follow Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. These guidelines state that certain codes are manifestation codes, denoted with a code first note, or 
in diseases classified elsewhere in the code definition. Another diagnosis code should be sequenced before a 
manifestation code if applicable.  
 
We looked at the file and Medicare rules. This claim was billed with primary diagnosis code Z99.3. This code 
is not an appropriate primary diagnosis as the code has a Code first note indicating to code the underlying 
condition first. Based on this information, we decided that Medicare rules for payment of this claim have not 
been met. Therefore, we decided that the Plan does not have to pay for the hospital bed provided on June 10, 
2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs rehabilitation to return to their 
pre-hospital status. You say the enrollee was approved prior to getting sepsis and needed to go back to acute 
care. The Plan denied your request. The Plan says the IRF services requested do not meet the requirements for 
approval.  
 
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. 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.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom fabricated abutment - includes placement tooth 
4,6,11,13 (D6057). 
 
You asked the Plan to pre-approve custom fabricated abutment - includes placement tooth 4,6,11,13. You say 
that this is medically necessary. The Plan denied your request. The Plan says this request is not medically 
necessary. A denture held in by implants is covered if x-rays sent by your provider shows the implant has fused 
well with the bone. The records sent show the implant has not fused well with the bone. 
 
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 custom 
fabricated abutment - includes placement tooth 4,6,11,13 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 custom fabricated abutment - includes 
placement tooth 4,6,11,13. Our reviewer says that the service is not medically necessary. Our physician 
reviewer found the criteria for coverage for custom abutment include adequate integration of bone to support 
the implant body. The radiographs provided did not include the implant bodies in areas #4, 6, 11 and 13, 
therefore a determination of adequate integration could not be made. 
 
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 custom fabricated abutment - includes placement tooth 4,6,11,13 have not been 
met. Therefore, we decided that the Plan does not have to pre-approve custom fabricated abutment - includes 
placement tooth 4,6,11,13 (D6057).
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 IRF services are both physically and medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet the 
requirements for an IRF admission.  
 
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 enrollees nursing, medical, and rehabilitation needs does 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 record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation program provided in an IRF. Medically necessary care can be provided in a different level of 
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 is declining and home health is not able 
to help. You say you are very concerned about the enrollee's mobility issues as they are not getting the proper 
treatment. The Plan denied your request. The Plan says the IRF services requested do not meet the 
requirements for approval.  
 
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. 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.  
 
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.