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

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341). 
 
You asked the Plan to pre-approve the dental services. You say that you are requesting reconsideration for the 
denial of periodontal scaling and root planing. 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. 
The Plan says 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 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 service is not medically necessary. Our physician reviewer found the documentation provided does not 
meet the criteria for coverage for periodontal scaling and root planing (D4341) in four quadrants. 
 
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 periodontal scaling and root planing (D4341).
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. The Plan denied your request. The Plan says the enrollee's records 
do not show you need for an intensive team (rehab doctor and nurse, social worker, and therapists) for care. 
Services needed may be provided safely in a lower level of care. 
 
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. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99204) and imaging studies (92611, 74230, 
72040) provided on December 9, 2022. 
 
You asked the Plan to pay for an office visit and imaging studies. You say that these services were medically 
necessary. The Plan denied your request. The Plan says these services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that when services are furnished in a mobile unit, 
they are often provided to serve an entity for which another Place of Service (POS) code exists. For example, a 
mobile unit may be sent to a physicians office or a skilled nursing facility. If the mobile unit is serving an 
entity for which another POS code already exists, providers should use the POS code for that entity.  
 
We looked at the file and Medicare rules. The services at issue were provided in a mobile unit servicing a nursing facility, but were billed with an office POS. Based on this information, we decided that Medicare rules 
for coverage of an office visit and imaging studies have not been met. Therefore, we decided that the Plan does 
not have to pay for an office visit (99204) and imaging studies (92611, 74230, 72040) provided on December 
9, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on December 21, 2022, billed 
with code 73560-26, LT. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the diagnosis is inconsistent with the procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that if a procedure code indicates laterality, the 
appropriate anatomical diagnosis must be assigned. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the imaging services provided have not been met. Procedure code 73560-26, LT was billed with 
diagnosis code Z96.659, described as presence of unspecified artificial knee joint, which is inappropriate. 
Therefore, we decided that the Plan does not have to pay for imaging services provided on December 21, 2022, 
billed with code 73560-26, LT.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 17, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on November 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care billed with code 99233 for 
December 16, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says payment is included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that post-operative services are included in the global 
surgical package. 
 
We looked at the file and Medicare rules. Procedure code 99233 was related to and billed within 10 days of 
minor surgical procedure code 36589 billed on December 14, 2022. Payment for code 99233 is included in the 
global surgical package for 36589. Therefore, we decided that the Plan does not have to pay for the subsequent 
hospital care billed with code 99233 for December 16, 2022.
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 meets the criteria for 
LTACH level of care that cannot be accomplished at a lower level of care.  The Plan denied your request. The 
Plan says an LTACH admission is not medically necessary, and the enrollee's needs can be met in another 
setting.  
 
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 does not require services at the LTACH that are not available at the 
acute care hospital where the enrollee is currently receiving care. The health plan has approved ongoing care in 
the current acute care setting. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a colonoscopy to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve the OON colonoscopy. You say that the records provided support the need 
for a colonoscopy.  The Plan denied your request. The Plan says the enrollee's needs can be met in-network.  
 
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 colonoscopy to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit billed with code 99342 for February 10, 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 billed place of service was inappropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The file shows that the claim was incorrectly billed with POS code 
13 for an assisted living facility. Therefore, we decided that the Plan does not have to pay for the home visit 
billed with code 99342 for February 10, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services rendered on March 2, 
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 provider type is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers services in freestanding emergency 
departments only if the emergency clinic is affiliated with a hospital. 
 
We looked at the file and Medicare rules. The provider is a freestanding ER not affiliated with a hospital. These 
services are not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the 
emergency room (ER) services rendered on March 2, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sucralfate. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Sucralfate.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mental health services provided by an out-of-network 
provider on December 8, 2022. 
 
You asked the Plan to pay for mental health services. You say that you have used this provider for a long time. 
The Plan denied your request. The Plan says this was not authorized. 
 
The Plan must follow Medicare rules. Medicare rules say that Health Maintenance Organizations (HMOs) may 
offer a Point of Service (POS) option as a mandatory or optional supplemental benefit and may either require 
or waive prior authorization rules for obtaining POS services. The Plan contract says that out-of-network 
outpatient mental health care requires authorization. 
 We looked at the file and Medicare rules. The service at issue was not authorized. Based on this information, 
we decided that Medicare rules for coverage of mental health services have not been met. Therefore, we 
decided that the Plan does not have to pay for mental health services provided by an out-of-network provider 
on December 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Inogen portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve oxygen equipment. You say that your current oxygen tank is considered 
portable but is still too heavy for you to move around. The Plan denied your request. The Plan says the notes do 
not show documentation that the current portable oxygen concentrator system is not meeting the enrollee's 
needs. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a standard portable oxygen concentrator, which the records show is valid until 
July 19, 2023. The standard portable oxygen concentrator serves the same purpose as the requested oxygen 
equipment. Therefore, we decided that the Plan does not have to pre-approve the Inogen portable oxygen 
concentrator (E1392).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PureWick catheter.  
 
You asked the Plan to pre-approve incontinence supplies. You say that the enrollee is not able to get out of bed 
to use the bathroom at night. The Plan denied your request. The Plan says the notes do not show this equipment 
is necessary and reasonable for the treatment of your illness or injury 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve a PureWick catheter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 29, 2022, billed 
with codes 81201, 81295, 81298, 81307, and 81317. 
 
You asked the Plan to pay for the genetic testing billed. You say that these are payable codes with no 
limitations. The Plan denied your request. The Plan says panel testing should be billed using one CPT code on 
the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code.  
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
November 29, 2022, billed with codes 81201, 81295, 81298, 81307, and 81317.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intracardiac echocardiography (93662) provided on 
October 17, 2022. 
  You asked the Plan to pay for the intracardiac echocardiography (93662). The Plan denied your request. The 
Plan says procedure code 93662 was billed without an appropriate primary 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 93662 
is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for the intracardiac echocardiography (93662) provided on October 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient stay for the approved surgery. 
 
You asked the Plan to pre-approve an inpatient stay for the approved surgery. You say that the requested 
inpatient stay for the approved surgery is medically necessary. The Plan denied your request. The Plan says the 
requested inpatient stay for the approved surgery 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 an inpatient stay for the approved 
surgery. Our reviewer says that the requested inpatient stay for the approved surgery is not medically 
necessary. Our physician reviewer found the enrollee was being treated for unilateral primary osteoarthritis of 
the left hip. Past medical history was positive for short-term memory loss and arthritis. He presented with pain 
in the left hip that is rated at 10/10. The exam reveals an obese male with marked irritability with hip range of 
motion. The treatment plan included a left total hip arthroplasty.  
 
However, detailed documentation is not evident regarding a significant past and/or current medical history that 
would place this enrollee at increased risk for peri-surgical complications requiring an inpatient stay.  There is 
no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the inpatient stay, in this case, 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 an inpatient stay for the approved surgery have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an inpatient stay for the approved surgery.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Foundation Pain Index (0117U) provided May 18, 2022.  
 
You asked the Plan to pay for the laboratory service. You say that Foundation Pain Index is a multi-analyte 
assay with algorithmic analysis that improves patient outcome by identifying underlying, treatable causes of 
pain. The Plan denied your request. The Plan says this service is not covered by Medicare. 
 
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. CPT code 0117U is non-covered for pharmacogenomic testing. 
Based on this information, we decided that Medicare rules for coverage of the laboratory service have not been 
met. Therefore, we decided that the Plan does not have to pay for the Foundation Pain Index (0117U) provided 
May 18, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided on November 23, 2022, billed with 
code 93971. 
 
You asked the Plan to pay for the testing services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim was billed with an invalid diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that if a bilateral code is provided and the condition is 
bilateral, then the bilateral code must be assigned.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing services provided have not been met. Procedure code 93971 was not billed with the 
correct bilateral diagnosis code. Therefore, we decided that the Plan does not have to pay for testing services 
provided on November 23, 2022, billed with code 93971.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vaccine administration (90471) provided on December 
20, 2022. 
 
You asked the Plan to pay for the vaccine service. You say that you should be reimbursed the $44 for this 
service. The Plan denied your request. The Plan says this vaccine service is not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine service. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine 
service.  Therefore, we decided that the Plan does not have to pay for the vaccine administration (90471) 
provided on December 20, 2022.  
 Benefits for the vaccine service may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve a portable oxygen concentrator (E1392). You say that the portable oxygen 
tanks that are provided to you are very heavy and bulky to be used out of the house for appointments. The Plan 
denied your request. The Plan says you are currently being provided with the most appropriate equipment that 
meets your needs. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a home fill unit with D-tanks. The home fill unit with D-tanks serve the same 
purpose as a portable oxygen concentrator (E1392). Therefore, we decided that the Plan does not have to pre-
approve a portable oxygen concentrator (E1392).