Persius/hicric huggingface dataset:
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 had a stroke last year and has not fully 
recovered. You say that the enrollee's spouse cannot help them with their therapy he needs at home. The Plan 
denied your request. The Plan says an IRF admission is not medically necessary.  
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95870-26 billed for date of service February 
15, 2023. 
 
You asked the Plan to pay for procedure code 95870-26. You say that the claim is billed correctly and should 
be paid. The Plan denied your request. The Plan says payment for code 95870-26 is bundled into payment for 
code 95861. 
 
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 
95870-26 is a column II code to column I code 95861. 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 95870-26 billed for date of service 
February 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service May 4, 2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to 1, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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 81456 is a column II code to column I code 81455 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Please note that the NCCI 
indicator change that you reference was not officially implemented until October 1, 2023. This date is well 
after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the right to 
submit the claim again for additional consideration based on the rule change. Therefore, we decided that the 
Plan does not have to pay for procedure code 81456 billed for date of service May 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for wound care service on March 30, 2023, to 
July 06, 2023. 
 
You asked the Plan to waive the copayment for wound care service. You say that you go weekly for wound 
care clean up and are being billed a surgery copay when all you do is go to the office for the skin around the 
wound to be cleaned up. 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 $280 
copayment per visit for outpatient surgery. The provider billed in the amount of $623.75 and allowed amount is 
$167.90. This is less than the copayment amount. There were thirteen visits. 13 x $167.90 = $2,182.70. 
Therefore, results in the total cost shairng amount of $2,182.70. 
 You have been asked to pay a $280 copayment for each wound care service. This item/service falls within the 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
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 wound care service on March 30, 
2023, to July 06, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty at L5 (22514). 
 
You asked the Plan to pre-approve kyphoplasty at L5. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebroplasty and percutaneous 
vertebral augmentation (PVA or Kyphoplasty) procedures will be considered medically reasonable and 
necessary for certain indications. 
 
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 at L5. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found detailed documentation is not 
evident regarding a progression of the body height loss, greater than 25% vertebral body height loss, kyphotic 
deformity, or a severe impact on daily activities. Moreover, there is magnetic resonance imaging (MRI) 
corroboration of other plausible causes of pain. Therefore, you do not meet the coverage criteria detailed in the 
LCD. 
 
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 at L5 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve kyphoplasty at L5 (22514).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve the CGM and supplies. You say that the CGM would be beneficial to the 
enrollee. The Plan denied your request. The Plan says criteria for the CGM have not been met.  
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM and supplies. Our reviewer 
says that the CGM and supplies are not medically necessary. Our physician reviewer found coverage criteria 
for CGM require insulin use or low blood glucose sugar. There is no mention of low blood glucose sugar that 
the enrollee is having. The enrollee has used a meter in the past and no longer uses the libre. Although the A1C 
is high, there is no mention of insulin being prescribed. The enrollee does not use lancets and hence is not 
monitoring blood glucose sugar much but we are not told why. 
 
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 CGM and supplies have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a continuous glucose monitor (CGM) and supplies.
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 was referred by their family 
practice physician for myoelectric orthotic restoration, using the MyoPro Motion G. The Plan denied your 
request. The Plan says the MyoPro orthosis is not yet known to be effective, based on scientific evidence, 
professional standards, and expert opinion, in improving health outcomes. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 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 heavy duty extra wide hospital bed (E0303). 
 
You asked the Plan to pre-approve a hospital bed. You say that you are appealing the denial because you need 
the bed because you cannot walk. The Plan denied your request. The Plan says the provided limited records do 
not support that the enrollee meets the criteria. 
 
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. The enrollee's weight is not documented in the records therefore, the weight criteria cannot be determined. Based on this information, we decided that Medicare rules for coverage 
of a hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve heavy 
duty extra wide hospital bed (E0303).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0012M) provided on April 20, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0012M) provided on April 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on April 18, 2023. 
 
You asked the Plan to pay for OIVIT services. 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 codes. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on April 18, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient psychiatric hospital services provided from  
March 15, 2023, to March 21, 2023. 
 
You asked the Plan to pay for the inpatient psychiatric hospital services. You say that the services were 
medically necessary. The Plan denied your request. The Plan says records from Centers for Medicare & 
Medicaid Services (CMS) indicate all 190 days of lifetime benefit in a psychiatric hospital have been used. 
 
The Plan contract says the Plan covers up to 190 days in a lifetime for inpatient mental health care in a 
psychiatric hospital. 
 
We looked at the file and the Plans rules. The file shows that the enrollee has used the 190 days of lifetime 
benefit in a psychiatric hospital. Based on this information, we decided that the Plans rules for coverage of the 
inpatient psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to 
pay for inpatient psychiatric hospital services provided from March 15, 2023, to March 21, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve retainer crown - porcelain/ceramic tooth #'s 9, 10 and 13 (D6740), 
core buildup, including any pins when required tooth #'s 9, 10, and 13 (D2950), and pontic - porcelain/ceramic 
tooth #'s 11 and 12 (D6245). 
 
You asked the Plan to pre-approve the dental services. You say that to properly restore the upper left and 
proper occlusion the proposed 5 unit bridge is the best option. In view of the perio condition double abutting in 
the anterior is indicated and the fixed bridge will help stabilize the perio.  The Plan denied your request. The 
Plan says that the requested services did not meet criteria for coverage after clinical review and because 
splinting procedures are excluded. 
 
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 dental services are medically necessary. Our physician reviewer found the documentation indicates that 
teeth #11 and 12 are missing. Teeth #'s 9, 10 and 13 have large restorations with recurrent caries. Teeth #'s 9, 
10, and 13 have 50% bone support which is adequate for a fixed bridge. A bridge replacing teeth #'s 11 and 12 
is medically reasonable using #'s 9, 10 and 13 as abutment retainers with core buildups. It is my opinion that 
the prognosis for a fixed bridge is better than a removable appliance due to less stress on the abutments. 
 
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 been met. Therefore, we decided that the Plan has to 
pre-approve retainer crown - porcelain/ceramic tooth #'s 9, 10 and 13 (D6740), core buildup, including any pins 
when required tooth #'s 9, 10, and 13 (D2950), and pontic - porcelain/ceramic tooth #'s 11 and 12 (D6245).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing, 15-21 drug class(es) (G0482) provided 
March 3, 2023. 
 
You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the drug testing have been met. the 
submitted lab results did not include documentation of the appropriate method of testing to meet this code 
description. Therefore, the billed service cannot be verified. It is noted that multiple attempts were made to 
contact the provider for additional information. Therefore, we decided that the Plan does not have to pay for the 
drug testing, 15-21 drug class(es) (G0482) provided March 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Cala transcutaneous afferent patterned stimulation 
(TAPS) therapy (K1018, K1019). 
 
You asked the Plan to pre-approve Cala TAPS therapy. You say that you request reconsideration of the denial 
of Cala TAPS therapy for the enrollee. The Plan denied your request. The Plan says the requested device is still 
being studied and 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 looked at the file and Medicare rules. Currently, the Cala TAPS device is still being studied to see if the 
treatment is reasonable and necessary. Additional research is needed to determine if this device provides a 
benefit of equal or greater value than the current recognized methods of treating essential tremor. Based on this 
information, we decided that Medicare rules for coverage of Cala TAPS therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve the Cala transcutaneous afferent patterned stimulation 
(TAPS) therapy (K1018, K1019).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on May 22, 2023. 
 
You asked the Plan to pay for a home visit. You say that patient is in a nursing facility and should not have 
needed a referral or authorization. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a home visit provided on 
May 22, 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 admission for additional extensive physical 
therapy and unable to get a wheelchair into your bathroom at home. The Plan denied your request. The Plan 
says you would not be able to tolerate 3 hours of physical therapy daily and do not meet criteria for 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 the complexity of your 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sport back (K0108), accessory bar (K0108), and seat 
liner (K0108). 
 
You asked the Plan to pre-approve the item. You say that the item is medically necessary. The Plan denied your 
request. The Plan says  the sport back and accessory bar do not serve a medical purpose and cannot be covered. 
The Plan also says the seat liner does not meet the coverage criteria. 
 
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 item. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the seat liner is coded K0108, but seat cushions are all inclusive and may not be unbundled and 
coded as K0108. The medical necessity for the liner is not addressed. 
 
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 item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a sport back (K0108), accessory bar (K0108), and seat liner (K0108).