Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 81226, 81240, 81241, 
81328, and 81479. We decided that the Plan does not have to pay for the services described by procedure 
code(s) 81225, 81231, 81232, 81335, and 81306.  
 
You asked the Plan to pay for procedure codes 81226, 81240, 81241, 81328, 81479, 81225, 81231, 81232, 
81335, and 81306 provided on June 21, 2023. You say that you would like the Plan to reconsider their denial of 
payment. The Plan says that the services are not covered as billed. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 81226, 81240, 81241, 
81328, and 81479.  
 
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. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 81226, 81240, 81241, 81328, 
and 81479.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
81225, 81231, 81232, 81335, and 81306. 
 
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 procedure codes 81225, 
81231, 81232, 81335, and 81306 have not been met. Therefore, we decided that the Plan does not have to pay 
for the services described by procedure code(s) 81225, 81231, 81232, 81335, and 81306. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tiering exception for Yupelri. 
 
You asked the Plan to pre-approve Yupelri. You say that you want the cost-sharing lowered. The Plan denied 
your request. The Plan says drug tiering exceptions are not covered for Medicare Part B prescription drugs. 
 
The Plan must follow Medicare rules. Medicare rules state that tiering exceptions cannot apply to Part B drugs. 
Tiering exceptions are only applicable to Part D drugs.  
 
We looked at the file and Medicare rules. The drug you are requesting is considered a Part B drug. As a result, 
no tiering exceptions can be made. Therefore, we decided that the Plan does not have to pre-approve a tiering 
exception for Yupelri.
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 are appealing with records. The Plan denied 
your request. The Plan says the denial of IRF care is correct.  
 
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 can be provided 
in a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach 
to rehabilitation care. The enrollee requires treatment by multiple therapies, including physical therapy and 
occupational therapy, but this can be provided in a lower level of care. There is documentation that there is a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF, but the services required can be provided at a lower level of 
care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a breast prosthesis and the mastectomy bra 
provided on July 06, 2023. 
 
You asked the Plan to waive the coinsurance for a breast prosthesis and the mastectomy bra. You say that you 
disagree with the coinsurance. 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 10% 
coinsurance for prosthetic devices and related supplies. 
 
You have been asked to pay 10% coinsurance for a breast prosthesis and the mastectomy bra. This item/service 
falls within the prosthetic devices and related supplies 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. The total amount you owe is $51.64 ($516.40 allowed 
amount x 10% = $51.64). Therefore, we decided that the Plan does not have to waive the coinsurance for a 
breast prosthesis and the mastectomy bra provided on July 06, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periapical radiographic image (D0220) and periapical 
additional image (D0230) provided on August 24, 2023. 
 
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 requested item or service was exhausted on date of service January 27, 2023. 
Therefore, we decided that the Plan does not have to pay for periapical radiographic image (D0220) and periapical additional image (D0230) provided on August 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for retainer crown (D6750), bone replacement graft (D7953), 
and removal of impacted tooth (D7240) provided on August 9, 2023.  
 
You asked the Plan to pay for these dental services. You say that this should be covered. The Plan denied your 
request. The Plan says this is not a covered service. 
 
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, 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 retainer 
crown (D6750), bone replacement graft (D7953), and removal of impacted tooth (D7240) provided on August 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an OON provider on September 
22, 2023. 
 
You asked the Plan to pay for the dental services. You say that this was medically necessary. The Plan denied 
your request. The Plan says the dental services were received from an out-of-network provider and are not 
covered by your supplemental benefits.  
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided by an OON provider on September 22, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from September 5, 
2023, to September 6, 2023. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you went to the emergency room via 
ambulance. You say that you were there longer than seven hours. You also say that this should be reprocessed 
and paid. The Plan denied your request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the provided records indicate that your workup was otherwise unremarkable, and 
vitals were stable following rate control. The reviewer found that you were not expected to require hospital 
services that would likely have crossed 2 midnights, and it was not expected that you would have an adverse 
event. Therefore, the reviewer found that the inpatient care was 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from September 5, 2023, to September 
6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitoring supplies billed for date of 
service August 26, 2023. 
 
You asked the Plan to pay for the billed services. You say that relevant documentation was provided. The Plan 
denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 Although the provider is a Medicare DME supplier, the record does not contain relevant medical records which 
support medical necessity for the supplies provided in this case. Based on this information, we decided that the 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
the continuous glucose monitoring supplies billed for date of service August 26, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve admission to a skilled nursing facility. You say that you feel that you are not 
back to baseline health and can only get back to baseline if you are in intensive rehabilitation in a SNF. The 
Plan denied your request. The Plan says you have used all 100 skilled nursing facility days that are covered 
under your medical insurance plan during your September 7, 2023, to December 15, 2023 SNF care. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from 09/07/2023 through 
12/15/2023. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the partial denture (D5660), additional tooth (D5650), and 
broken tooth replacement (D5640). 
 
You asked the Plan to pay for the partial denture, additional tooth, and broken tooth replacement. You say that 
the services were medically necessary. The Plan denied your request. The Plan says these are not covered 
services. 
 
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, 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 the partial 
denture (D5660), additional tooth (D5650), and broken tooth replacement (D5640).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), of diagnostic or therapeutic substance(s) 
(62323). 
 
You asked the Plan to pre-approve injections. You say that you need your injections because you are trying to 
reframe from having back surgery. The Plan denied your request. The Plan says you do not meet criteria for 
approval of injections. 
 
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 injections. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the epidural steroid injection on September 25, 2023, provided only 60% pain relief for a period 
of one week. In addition, there is no documentation provided indicating that the provider would use a different 
approach, level and/or medication for the requested repeat epidural steroid injection. The review has 
determined that you do not meet criteria for approval of the requested injections. The ESI 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 injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve injection(s), of diagnostic or therapeutic substance(s) (62323).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair with multiple 
power options (K0861) and additional items and accessories (codes E0955, E0956, E1007, E1012, E1028, 
E2311, E2313, E2361, E2377, E2607, E2620, and K0108). 
 
You asked the Plan to pre-approve a Group 3 standard power wheelchair and additional items and accessories. 
You say that the enrollee has hemiplegia affecting the left side of their body, which renders them functionally 
non-ambulatory. It also 
significantly decreases their strength and functional range of motion on half of their body, which severely 
limits their independence regarding the completion of self-care tasks. You also say that this is clearly and 
repeatedly outlined in the enrollee's mobility evaluation, which highlights their mobility deficits and need for 
power mobility to increase his safety and functional independence in and around their home. The Plan denied 
your request. The Plan says the enrollee does not have a medical need for multiple power options available 
with a K0861 group 3 power wheelchair. An expandable controller, harness, electronics, and power elevating 
leg rests are not medically needed. The Plan also says the swingaway hardware is miscoded, and armrests 
(K0108) are unbundled. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair (PWC) with multiple 
power options (such as code K0861) is covered if the criteria listed in the Medicare rules section of this letter 
are met. Medicare rules also say that if the PWC base is not covered, then related accessories will be denied. 
 
 
 
 
 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 a Group 3 standard power wheelchair 
and additional items and accessories. Our reviewer says that the criteria for coverage have not been met. Our 
physician reviewer found the enrollee has a neurologic disorder with functional deficits.  The documentation 
does not indicate that the enrollee has any pressure injuries or requires intermittent catheterization of the 
bladder or have spasticity that would necessitate power tilt or recline. Our reviewer found that although the 
enrollee's condition may meet criteria for a PWC, the criteria for this specifically requested power wheelchair 
are not met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Group 3 standard power wheelchair and additional items and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 standard power 
wheelchair with multiple power options (K0861) and additional items and accessories (codes E0955, E0956, 
E1007, E1012, E1028, E2311, E2313, E2361, E2377, E2607, E2620, and K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitoring supplies billed for date of 
service August 20, 2023. 
 
You asked the Plan to pay for the billed services. You say that relevant documentation was provided. The Plan 
denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. In this case, the documentation does not show that the enrollee had a recent (within the last 6 
months) in-person visit with their treating physician to evaluate their diabetes control and to determine whether 
the criteria for coverage have been met. Therefore, we decided that the Plan does not have to pay for the 
continuous glucose monitoring supplies billed for date of service August 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the knee orthosis (L1851). 
 You asked the Plan to pre-approve the orthosis. You say that please see attached medical records to support this 
appeal. The Plan denied your request. The Plan says based on Medicare guidelines, the knee brace (knee 
orthosis) L1851 requested does not meet the requirements for approval. 
 
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 orthosis. 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 bilateral chronic arthritis and no recent surgery or injury and no instability. The 
orthosis 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 the orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the knee orthosis (L1851).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an OON provider on August 22, 
2023. 
 
You asked the Plan to pay for the dental services. You say that this was medically necessary. The Plan denied 
your request. The Plan says the dental services were received from an out-of-network provider and are not 
covered by your supplemental benefits.  
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided by an OON provider on August 22, 2023.