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

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services (HHS). You say that the enrollee needs the requested 
services because they had multiple incidents where they fell and had fractures. The Plan denied your request. 
The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services (HHS). Our 
reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found that 
the enrollee does not currently have documented skilled nursing or skilled therapy needs. Home health aide 
(HHA) services must be in conjunction with skilled nursing or skilled therapy. HHS must be intermittent, not 
daily, or continuous. As such, the requested, 24 hours a day HHA services are not medically necessary, 
reasonable, or coverable. 
 
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 (HHS) have not been met. Therefore, we decided that the 
Plan does not have to pre-approve home health services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair. 
 
You asked the Plan to pre-approve a group 3 power wheelchair. You say that this is medically necessary as the 
enrollee has difficulty maneuvering a manual wheelchair. The Plan denied your request. The Plan says the 
enrollee does not have a qualifying diagnosis causing mobility limitation for which a group 3 power wheelchair 
is medically needed. 
   
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, 
myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a 
group 3 power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation  problem focused (D0140) and 
endodontic therapy, molar tooth (D3330) provided on November 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the limited oral evaluation was exhausted on date of service June 24, 2022. Your yearly 
maximum was met during your visit for the endodontic therapy, molar tooth. Therefore, we decided that the 
Plan does not have to pay for limited oral evaluation  problem focused (D0140) and endodontic therapy, 
molar tooth (D3330) provided on November 23, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services provided on September 23, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed 
services cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and the rules. The rendering provider on the claim submitted does not match the 
rendering provider on the medical records. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
the physical therapy services provided on September 23, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve crown - porcelain/ceramic (D2740) Tooth #14. 
 
You asked the Plan to pre-approve dental services. You say that you feel the denial is not logical. The Plan 
denied your request. The Plan says that the request is not medically necessary. 
 
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 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 dental services. Our physician reviewer 
found as the tooth has a previous crown on it, the only type of restoration that can  be used is another 
crown. Given the clinical situation it does appear that a replacement crown would meet the Plan criteria. 
 
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 dental services have been met. Therefore, we decided that the Plan has to pre-
approve crown - porcelain/ceramic (D2740) Tooth #14.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service August 31, 
2022. 
 
You asked the Plan to pay for procedure code 99053. You say that this service was medically necessary. The 
Plan denied your request. The Plan says procedure code 99053 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 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service August 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are 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 the enrollee is modestly deconditioned after surgery and rehospitalization. The 
enrollee has no barriers to recovery. They do not have complex or intensive rehabilitation needs to recover 
from their back surgery. The enrollee is at contact guard assist for transfers. IRF is not medically 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4550 billed for date of service November 
23, 2022. 
 
You asked the Plan to pay for procedure code A4550. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code A4550 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 A4550 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code A4550 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code A4550 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A4550 billed for date of service November 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DecisionDx-Melanoma testing provided on November 2, 
2022. 
 You asked the Plan to pay for DecisionDx-Melanoma testing. You say that this test was ordered by the 
enrollee's physician to inform treatment decisions. The Plan denied your request. The Plan says this request is 
not medically necessary because the enrollee's records do not show T1a melanoma with documented concern 
about adequacy of microstaging. 
 
The Plan follows Medicare rules. Medicare rules say that thist test is covered when the enrollee has a personal 
history of melanoma and either has Stage T1b and above or T1a with documented concern about adequacy of 
microstaging. 
 
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 DecisionDx-Melanoma testing. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found that per the National 
Comprehensive Cancer Network (NCCN) Guidelines: the use of gene expression profiling (GEP) testing 
according to specific AJCC-8 melanoma stage requires further prospective investigation in large, contemporary 
data sets of unselected patients. Prognostic GEP testing to differentiate melanomas at low versus high risk for 
metastasis should not replace pathologic staging procedures. Moreover, since there is a low probability of 
metastasis in stage I melanoma and a higher proportion of false-positive results, GEP testing should not guide 
clinical decision-making in this subgroup. On an individual basis, the likelihood of a positive sentinel lymph 
node biopsy (SLNB) may be informed by the use of multivariable nomograms/risk calculators and ongoing 
investigation of GEP tests. The use of DecisionDx melanoma is not reasonable or medically 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 DecisionDx-Melanoma testing have not been met. Therefore, we decided that 
the Plan does not have to pay for DecisionDx-Melanoma testing provided on November 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99408 billed for date of service October 29, 
2022. 
 
You asked the Plan to pay for procedure code 99408. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says payment for code 99408 is bundled into 
payment for code 99406. 
 
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 99408 
is a column II code to column I code 99406 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. Therefore, we decided that 
the Plan does not have to pay for procedure code 99408 billed for date of service October 29, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for the skilled nursing facility (SNF) care provided from July 20, 2022, to 
July 31, 2022. 
 
You asked the Plan to pay for the SNF care. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan has not provided enough evidence to support the denial of 
payment for the SNF services based on Medicare criteria. The Plan provided no evidence that the discharge day 
was August 1, 2022. Therefore, we decided that the Plan has to pay for the skilled nursing facility (SNF) care 
provided from July 20, 2022, to July 31, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (K0553, K0554) provided on 
November 28, 2022. 
 
You asked the Plan to pay for a continuous glucose monitor. You say that you want the Plan to reconsider the 
denial. The Plan denied your request. The Plan says this is not medically necessary because the records do not 
show the enrollee requires insulin three or more times daily. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pay for a 
continuous glucose monitor (K0553, K0554) provided on November 28, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the noninvasive ear or pulse oximetry for oxygen saturation; 
single determination (94760) provided on May 16, 2022. 
 
You asked the Plan to pay for the measure of blood oxygen level. You say that the services were medically 
necessary. The Plan denied your request. The Plan says procedure code 94760 has a status indicator of "T" and 
is bundled into payment for other services G2212 billed on the same day by the same provider under the 
physician fee schedule. 
 
The Plan must follow Medicare rules. Medicare rules say that the Physician Fee Schedule Status Indicator 'T' 
means that payment for covered services is always bundled into another payable physician service.  
 
We looked at the file and Medicare rules. Per review of the records, procedure code 94760 has a status 
indicator of T on the CMS National Physician Fee Schedule (NPFS) Relative Value (RVU) file. This means 
this service is always bundled into another payable physician service, G2212, billed the same day by the same 
provide. Based on this information, we decided that Medicare rules for coverage of the measure of blood 
oxygen level have not been met. Therefore, we decided that the Plan does not have to pay for the noninvasive 
ear or pulse oximetry for oxygen saturation; single determination (94760) provided on May 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676). 
 
You asked the Plan to pay for a pneumatic compression device. You say that you want the Plan to pay for this. 
The Plan denied your request. The Plan says this is not covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diabetic shoes (A5500), and inserts (A5512). 
 
You asked the Plan to pre-approve the diabetic shoes and inserts. You say that the member has diabetes 
mellitus. The Plan denied your request. The Plan says the medical information provided indicates that the 
enrollee has diabetes; however, it does not indicate if they have any foot deformity, calluses, amputation, poor 
circulation, or history of previous foot ulcerations. There is insufficient information to determine if the enrollee 
meets the Medicare rules for the diabetic shoes and inserts. 
 
The Plan must follow Medicare rules. Medicare rules say that the certifying physician has certified that  
indications (1) and (2) listed above are met indicating any foot deformity, calluses, amputation, poor 
circulation, or history of previous foot ulcerations. We looked at the file and Medicare rules. Based on this 
information, we decided that Medicare rules for coverage of the diabetic shoes and inserts have not been met. 
Therefore, we decided that the Plan does not have to pre-approve diabetic shoes (A5500), and inserts (A5512).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoperative neuromonitoring services provided to the enrollee on May 4, 2022.
You asked the Plan to pay for the intraoperative neuromonitoring services. You say that these services were medically necessary. The Plan denied your request. The Plan says that the codes are not supported in the documentation.
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, the CPT Code Manual definition of code 95886 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited, of code 95955 is an electroencephalogram (EEG) during nonintracranial surgery, and of code 95908 is nerve conduction studies for 3-4 studies. We asked our Medical Director 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 intraoperative neuromonitoring services. Our Medical Director says that provided records including the operative report in this case do not document a complete needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (95886), a complete nerve conduction study for 3-4 studies (95908), or an electroencephalogram (EEG) during nonintracranial surgery (95955) for carotid endarterectomy, cerebral aneurysm clipping, epilepsy surgery or monitoring depth of anesthesia. Our Medical Director found that the record does not substantiate that these services were supported in the documentation. 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 intraoperative neuromonitoring services have not been met. Therefore, we decided that the Plan does not have to pay for the intraoperative neuromonitoring services provided to the enrollee on May 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with procedure code 0241U for 
date of service November 30, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the claim for this molecular pathology testing did not include the 
required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services billed 
with procedure code 0241U for date of service November 30, 2022.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic radiology services provided to the enrollee on May 7, 2022.

You asked the Plan to pay for the diagnostic radiology services. You say that the enrollee was inpatient at the time of the services being provided. The Plan denied your request. The Plan says Original Medicare is responsible for payment.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.

The enrollee ended Medicare Hospice benefits on May 7, 2022. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the diagnostic radiology services provided to the enrollee on May 7, 2022.