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

 
We decided that the Plan does not have to pay for home visit provided on January 20, 2023. 
 
You asked the Plan to pay for home visit. You say that you are appealing the claim payment denial. 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 home visit provided on 
January 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service July 10, 
2022. 
 
You asked the Plan to pay for procedure code 99291. You say that the -FT modifier was appended. The Plan 
denied your request. The Plan says payment for code 99291 is bundled into payment for code 36556. 
 
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 99291 is a column II code to column I code 36556. Although code 
99291 was billed with modifier -FT, there are no medical records to show that the evaluation and management 
code was unrelated to procedure code 36556.. 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 99291 billed for date of 
service July 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675). 
 
You asked the Plan to pay for the pneumatic compression device. You say that the item was medically 
necessary. The Plan denied your request. The Plan says it was not medically necessary. 
 
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 the pneumatic compression device (E0675).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen concentrator (E1390) provided on February 3, 
2023. 
 
You asked the Plan to pay for the oxygen concentrator. You say that your doctor prescribed oxygen for you at 
night, and you decided to purchase a low-cost unit. You also say that it would have cost the Plan much more in 
the long run to pay for a rental. The Plan denied your request. The Plan says it was confirmed that the provider 
the oxygen concentrator was purchased from is not included in Medicares Supplier Directory as a certified 
durable medical equipment provider. The Plan also says that there were providers available for you to have 
received items that were certified within 25 miles of you. 
 
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items 
or services, a provider or supplier must be enrolled in the Medicare program. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the oxygen concentrator have not been met. The durable medical equipment (DME) provider is not 
part of the Medicare program and is not payable. Therefore, we decided that the Plan does not have to pay for 
the oxygen concentrator (E1390) provided on February 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6245) for tooth #3 and retainer crowns 
(D6740) for tooth #2 and #4. 
 
You asked the Plan to pre-approve the dental services. You say that it is medically necessary that you get a 
permanent bridge. The Plan denied your request. The Plan says you have missing teeth on both sides of the 
arch; therefore, the requested dental services are 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 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 bridge from toot #2 to tooth #4 would not be reasonable or necessary given the periodontal status of the 
teeth. Our physician reviewer found that the proposed abutment for teeth #2 and #4 both have significant 
periodontal involvement with more than 50% missing bone evident on the provided x-ray. The teeth are not 
suitable as abutment teeth to replace tooth #3. In addition, the Plan allows for a bridge when appropriate where 
there is a missing tooth or teeth on one side of the arch, and not both. In this case there is also missing tooth 
#13 and tooth #15 on the opposing side of the arch. Given the poor periodontal condition of the teeth as well as 
there being missing teeth on both sides of the arch there would be no necessity for the requested bridge. 
 
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 a pontic (D6245) for tooth #3 and retainer crowns (D6740) for tooth #2 and #4.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wig (A9282). 
 
You asked the Plan to pre-approve a wig. You say that you are requesting a cranial prosthesis due to hair loss 
because of chemotherapy treatments. The Plan denied your request. The Plan says this request is not medically 
necessary because this item is not considered durable medical equipment as it is not reasonable and necessary 
for treatment of illness or injury, it is not used to serve a medical purpose, and it is primarily for convenience or 
comfort. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve a wig (A9282).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive hearing test, and related services, 
provided on November 18, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the hearing services. You say that there is a referral for these services. The Plan 
denied your request. The Plan says enrollees must receive their care from a network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
items/services at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the comprehensive hearing test, and related 
services, provided on November 18, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for date of service December 
19, 2022. 
 
You asked the Plan to pay for the billed services. You say that the diagnosis code billed is payable. The Plan 
denied your request. The Plan says the diagnosis codes were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. We find that code 99233 was billed with diagnosis codes J96.01 and R09.02.0. Diagnosis code R09 has an 
excludes 1 note with diagnosis code J96.-. This means that these codes should never be used at the same 
time. 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 procedure code 99233 billed for date of 
service December 19, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you are requesting an expedited appeal for 
continuation of a SNF admission. The Plan denied your request. The Plan says your request for approval of 
continued admission in a SNF does not meet the requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. The enrollee's function was at or near their prior level of function and they could be 
discharged to a lower level of care for further services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home sleep test (95800). 
 
You asked the Plan to pre-approve a home sleep test. You say that the sleep study was ordered to requalify the 
enrollee for a new CPAP machine. The Plan denied your request. The Plan says this is not medically necessary. 
   
The Plan follows Medicare rules. Medicare rules say that follow-up polysomnography or sleep studies are not 
routinely indicated for patients treated with CPAP whose symptoms continue to be resolved with CPAP 
treatment. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home sleep test. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found this enrollee has a known diagnosis 
of obstructive sleep apnea and is on home continuous positive airway pressure (CPAP). Currently the device is 
not functioning, and the enrollee is unable to use it. It is 7 years old. There is no indication that the enrollee's 
CPAP was not meeting needs when it was functional. A sleep study is not necessary to qualify the enrollee for 
a replacement CPAP device. 
 
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 home sleep test have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home sleep test (95800).
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 for the 
enrollee's recovery. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 
criteria for admission to an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on March 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should be paid in full. The Plan denied your 
request. The Plan says your $2,500 annual maximum 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. Therefore, we decided that the Plan does 
not have to pay for dental services provided on March 3, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Monoferric (J1437). 
 You asked the Plan to pre-approve the Monoferric. You say that the drug is medically necessary. The Plan 
denied your request. The Plan says the enrollee has not met the step therapy requirements for this drug. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Monoferric. Our reviewer says that 
the enrollee has not met the step therapy requirements for this drug. Our physician reviewer found the case file 
does not contain documentation of trial and failure of two preferred products or that the two preferred products 
would likely be less effective, and/or would likely have adverse effects for the enrollee in this case.  
 
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 Monoferric have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Monoferric (J1437).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Comprehensive Mutli-Omic Solid Tumor Prognostic 
Predictive Panel (81455) provided on March 3, 2022. 
 
You asked the Plan to pay for the Next Generation Sequencing (NGS) panel. You say that the criteria for 
coverage are met. The Plan denied your request. The Plan says there is no documentation the enrollee has 
recurrent, relapsed, refractory, metastatic, or advance stage III or IV cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that NGS panels may be covered when the enrollee 
has either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Next Generation Sequencing (NGS) panel have not been met. Specifically, the provided 
documentation does not support that the enrollee has recurrent, relapsed, refractory, metastatic, or advanced 
stage III or IV cancer. Therefore, we decided that the Plan does not have to pay for the Comprehensive Mutli-
Omic Solid Tumor Prognostic Predictive Panel (81455) provided on March 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the shoulder sling provided on January 17, 
2023. 
 
You asked the Plan to waive the coinsurance for the shoulder sling. You say that you were not charged for a 
sling in the past. 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 20% 
coinsurance for durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for the shoulder sling. This item/service falls within the durable 
medical equipment 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 $16.02 ($80.08 allowed amount x 20% = 
$16.02). Therefore, we decided that the Plan does not have to waive the coinsurance for the shoulder sling 
provided on January 17, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the medical records support the medical necessity for 
IRF admission. The Plan denied your request. The Plan says based on Medicare guidelines and the information 
we have about the enrollee's condition they don't meet all of the requirements. 
 
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 enrollees nursing, rehabilitation and medical needs do not 
require an acute hospital inpatient rehabilitation stay with an interdisciplinary approach to rehabilitative care. 
While the enrollee may benefit from physical and occupational therapy, the enrollee's rehabilitation needs can 
be provided in an alternate setting such as in a skilled nursing facility. 
 
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 IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
 
You asked the Plan to pre-approve SNF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services cannot be approved at this time. 
 
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 March 1, 2023, through 
June 18, 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 skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the medical records support the medical necessity for 
IRF admission. The Plan denied your request. The Plan says the member does not meet the Medicare criteria 
for admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees nursing, rehabilitation and medical needs do not 
require an acute hospital inpatient rehabilitation stay with an interdisciplinary approach to rehabilitative care. 
While the enrollee may benefit from physical and occupational therapy, the enrollee's rehabilitation needs can 
be provided in an alternate setting such as in a skilled nursing facility. 
 
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 IRF admission and services.