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

 
We decided that the Plan does not have to pay for the telehealth services provided on January 31, 2023, by an 
OON provider.   
 
You asked the Plan to pay for the telehealth services. You say that the enrollee was not able to leave their home 
due to COVID-19 infection. The Plan denied your request. The Plan says the services were not 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 telehealth services provided on January 31, 
2023, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee does not meet the Medicare guidelines for 
admission to an IRF.  
 
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 that 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 enrollee may have a need for physical 
therapy 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 
the 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 an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that without ventilator therapy the enrollee is at high risk 
for hospitalization. The Plan denied your request. The Plan says a ventilator is not covered by Medicare for this 
purpose, and the enrollee's needs could be met by a bilevel positive airway pressure (BiPAP) device with 
average volume assured pressure support (AVAPS) mode. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide positive 
airway pressure (PAP) therapy, regardless of the underlying medical condition, shall not be covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve use 
of a ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray (D6245) provided on January 19, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
intraoral x-ray (D6245) provided on January 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services billed with code 88305 for February 
22, 2023. 
 
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 the services are not separately payable.  

The Plan must follow Medicare rules. The rules say that the PC and TC for diagnostic services are separately 
payable when furnished in different payment localities. 
 
We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different 
payment localities. 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 the pathology services billed 
with code 88305 for February 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep gum and root cleaning for all 4 quadrants (D4341). 
 
You asked the Plan to pre-approve deep gum and root cleaning. You say that this is medically necessary. The 
Plan denied your request. The Plan says your tooth must have noticeable bone loss or show on an x-ray that 
there is a hard substance built up on the root of the tooth. Your x-rays do not show that you have these issues. 
 
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 deep gum and 
root cleaning 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 deep gum and root cleaning. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the requested treatment is not medically necessary.  The supplied documentation does not show notable bone loss of four or more teeth 
in any one quadrant.  
 
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 deep gum and root cleaning have not been met. Therefore, we decided that the 
Plan does not have to pre-approve deep gum and root cleaning for all 4 quadrants (D4341).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay the in-network rate for the office visit provided on March 7, 
2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay the in-network rate for the physician service. You say that this should be covered at 
the in-network rate. The Plan denied your request. The Plan says out-of-network services are 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 the in-network rate 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 did not pre-approve the 
service at issue. We found no exception that would require the Plan to pay the in-network rate for these 
services. Therefore, we decided that the Plan does not have to pay the in-network rate for the office visit 
provided on March 7, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93040 billed for date of service December 
20, 2022. 
 
You asked the Plan to pay for procedure code 93040. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 93040 is bundled into payment for code 93306. 
 
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 93040 
is a column II code to column I code 93306. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 93040 billed for date of service December 20, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service December 
25, 2022. 
  
You asked the Plan to pay for procedure code 99100. You say that the claim should be reprocessed based on 
the anesthesia records and block notes. The Plan denied your request. The Plan says procedure code 99100 is 
considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service December 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve new handle push (K0108 x2), expandable controller 
(E2377), harness for upgrade to expandable controller (E2313), and electronic connection between wheelchair 
controller and two or more power seating system motors (E2311). 
 
You asked the Plan to pre-approve new handle push, expandable controller, harness for upgrade to expandable 
controller, and electronic connection between wheelchair controller and two or more power seating system 
motors. 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. 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 new handle push, expandable 
controller, harness for upgrade to expandable controller, and electronic connection between wheelchair 
controller and two or more power seating system motors. 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 adequate upper body strength to manage standard power drives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of new handle push, expandable controller, harness for upgrade to expandable 
controller, and electronic connection between wheelchair controller and two or more power seating system 
motors have not been met. Therefore, we decided that the Plan does not have to pre-approve new handle push 
(K0108 x2), expandable controller (E2377), harness for upgrade to expandable controller (E2313), and 
electronic connection between wheelchair controller and two or more power seating system motors (E2311).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF services provided on February 8, 2023, to February 23, 
2023, by an OON provider.  
 
You asked the Plan to pay for SNF services. You say that you are appealing the claim payment denial. The 
Plan denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 SNF services provided on February 8, 2023, to 
February 23, 2023, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an open sacroiliac (SI) fusion (27280). 
 
You asked the Plan to pre-approve an open sacroiliac fusion. You say that this is medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of an open SI joint fusion procedure in 
absence of sacroiliac joint instability, fracture, or tumor have not been demonstrated in the peer-reviewed 
literature. 
 
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 an open sacroiliac fusion. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found detailed documentation is not evident regarding imaging or radiographic evidence 
supporting a sacroiliitis pathology. There is no clear history of SI joint pain onset or failure of conservative 
treatment directed to the SI joint. Multiple other plausible pain generators including at the lumbosacral spine 
are evident. There are no updated examinations provided for review to corroborate that the enrollee's symptoms 
and objective deficits are ongoing. There are limited large-scale, long-term references showing the safety and 
efficacy of the requested surgery in this clinical setting. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
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 open sacroiliac fusion have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an open sacroiliac (SI) fusion (27280).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0105-53 billed for date of service February 
8, 2023. 
 
You asked the Plan to pay for procedure code G0105-53. You say that these services are payable together. The 
Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 

We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on February 27, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for procedure code G0105-53 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code G0105-53 billed for date of 
service February 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code P9604 billed for date of service August 8, 
2022. 
 
You asked the Plan to pay for procedure code P9604. You say that this service was necessary and was reported 
correctly. The Plan denied your request. The Plan says payment for code P9604 is bundled into payment for 
code P9603. 
 
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 P9604 
is a column II code to column I code P9603. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code P9604 billed for date of service August 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from July 24, 2023, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care. You say that inpatient psychiatric care is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested inpatient 
psychiatric care is not medically necessary.  

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care. Our reviewer 
says that inpatient psychiatric care from July 24, 2023, forward is not medically reasonable and necessary. Our 
physician reviewer found that based upon review of the records provided, it is not expected that the enrollee 
would improve in a reasonable period of time, as the enrollee is not showing any dangerousness to self or 
others, auditory or visual hallucinations and is without aggressive behaviors while not showing any acute 
threats of safety. It does not appear medically necessary and reasonable to have psychiatric care provided at the 
acute inpatient 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 inpatient psychiatric care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient psychiatric care from July 24, 2023, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wheelchair component or accessory, not otherwise 
specified, backup camera (K0108). 
 
You asked the Plan to pre-approve the backup camera. You say that due to the enrollee's chronic medical 
condition, the enrollee has limited mobility in the neck. The Plan denied your request. The Plan says this item 
does not meet the definition of DME as this item does not serve a medical purpose and, instead, functions as a 
convenience item. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the wheelchair component or accessory, not otherwise 
specified, backup camera (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prefabricated abutments for tooth 11 and tooth 13 
(D6056 x2), semi-precision attachment (D6192 x4), and a complete upper overdenture (D5863). 
 
You asked the Plan to pre-approve the dental services. You say that you want the Plan to cover these services. 
The Plan denied your request. The Plan says your benefit for the prefabricated abutments has been exhausted 
with the approval of tooth 4 and tooth 6. Semi-precision attachments and complete upper overdentures are not 
covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 with the Plan's approval for tooth 4 and 
tooth 6. Additionally, semi-precision attachments and complete upper overdentures are not covered benefits. 
Therefore, we decided that the Plan does not have to pre-approve prefabricated abutments for tooth 11 and 
tooth 13 (D6056 x2), semi-precision attachment (D6192 x4), and a complete upper overdenture (D5863).
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 a replacement cover for wheelchair seat cushion or back cushion (E2619). 
 
You asked the Plan to pre-approve an electronic connection, harness, expandable controller, and a replacement 
cover for wheelchair seat cushion or back cushion. You say that the enrollee requires the K0861 base and all 
recommended components to meet their mobility, medical, and functional needs in their home. The Plan denied 
your request. The Plan says there is not a medical need to control these power options through the joystick. The 
Plan also says a separate request for a replacement cover for the approved seat cushion should be denied as 
unbundled. 
 
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 an electronic connection, harness, 
expandable controller, and a replacement cover for wheelchair seat cushion or back cushion. 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 adequate upper body strength to manage standard power drives. Our 
reviewer also found that the seat cover replacement is not necessary as the enrollee is receiving new seat 
cushions with the approved power wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection, harness, expandable controller, and a replacement 
cover for wheelchair seat cushion or back cushion 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 a replacement cover for wheelchair seat cushion or back cushion (E2619).