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

 
We decided that the Plan has to pay for home health services provided from August 18, 2022, to September 16, 
2022. 
 
You asked the Plan to pay for home health services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says that rules for payment have not been met. 
 
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's denial indicates that the NOA pertaining to the home 
health services at issue was submitted untimely. The case record does not contain a copy of the untimely NOA 
to support the Plan's denial. It is the Plan's responsibility to support its denial with evidence. In this case, the 
denial has not been supported, so we must find in your favor. Therefore, we decided that the Plan has to pay for 
home health services provided from August 18, 2022, to September 16, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the facet denervation procedure (64636 x2, 64635 x2). 
 
You asked the Plan to pre-approve the facet denervation procedure. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the facet denervation procedure is not medically 
necessary. The Plan says the enrollee has had two radiofrequency sessions to the lumbar region within the 
previous 12 months. 
 
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 facet denervation procedure. Our reviewer says that the service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has already exceed the total number of ablation procedures in 12 months.  
 
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 facet denervation procedure have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the facet denervation procedure (64636 x2, 64635 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 2d oral/facial image (D0350) provided on April 11, 2023. 
 
You asked the Plan to pay for 2d oral/facial image. 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 2d 
oral/facial image (D0350) provided on April 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (87481-XU, 87653-XU, 87798-XU, 
87641-XU) provided on February 23, 2023. 
 
You asked the Plan to pay for the laboratory services. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we have confirmed that codes 87481-XU, 87653-XU, 87798-XU, 87641-XU, are a column II code 
to column I code 87150; however, 87481-XU, 87653-XU, 87798-XU, 87641-XU was billed with a modifier.  
 
We asked our coder 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 laboratory services. Our reviewer found the use of 
modifier XU is not supported, the codes are not separately identifiable procedures. 
 
We looked at this coder's review, the file, and Medicare rules. 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 (87481-XU, 87653-XU, 87798-XU, 87641-XU) provided on 
February 23, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee needs this care. The Plan denied your 
request. The Plan says the medical records do not show a need for SNF care. 
 
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. 
 
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 SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visits provided on November 11, 2022, to November 
13, 2022. 
 
You asked the Plan to pay for office visits. You say that you are requesting reconsideration for the services 
provided. 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 office visits provided on 
November 11, 2022, to November 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation and cleaning (D1110, D0120) 
provided on May 3, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 a periodic oral evaluation and cleaning (D1110, D0120) provided on May 3, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy (PT) services provided on January 7, 2022. 
 
You asked the Plan to pay for the therapy services. You say that multiple claims were denied without a specific 
reason. The Plan denied your request. The Plan says the claim was not filed within the required timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the therapy services was not filed until February 2, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for physical therapy (PT) services provided on January 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Ottobock C-leg 4 (L5828, L5845, L5848, L5856). 
 
You asked the Plan to pre-approve Ottobock C-leg 4. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Lower Limb Prostheses are covered when specific 
criteria are met. 
 
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 Ottobock C-leg 4. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the physician documentation does 
not reveal medical reasons that support that this enrollee's activities cannot be met with a mechanical knee. 
Further the requested Ottobock C leg 4+ has convenience features that exceed the enrollee's medical and 
functional needs such as MyModes and a companion Android app which would allow the enrollee to change 
modes quickly with Bluetooth technology for activities such as biking, golfing, walking or dancing. The 
requested knee allows enrollees to use a smartphone app called Cockpit that allows the user track steps right 
from their phone and allows water submersibility of up to one meter of water for 30 minutes. These features are 
not a medical necessity and are convenience features for this enrollee. The enrollee's needs can be safely and 
effectively met with a less complex knee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ottobock C-leg 4 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an Ottobock C-leg 4 (L5828, L5845, L5848, L5856).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve the service. You say that the enrollee cannot tolerate/complete at least 6 
weeks of physical therapy. The Plan denied your request. The Plan says there are conservative options 
available.  
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no specific indication provided to support the request for bone marrow aspirate for the approved surgery. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use 
of bone marrow aspirate for this enrollees medical condition as discussed above. No compelling rationale is 
presented, or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the requested bone marrow aspirate 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 the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the bone marrow aspirate (20939).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services provided on September 6, 2022. 
 
You asked the Plan to pay for the telehealth services. You say that per the medical records, these service are 
covered under the patient's benefit plan and are necessary for the patient. The Plan denied your request. The 
Plan says virtual care out-of-network is not covered. 
 
The Plan contract says that virtual care (also referred to as telehealth services, virtual check-ins or eVisits) is 
not covered out-of-network. 
 
We looked at the file and the Plans rules. The file shows that virtual care (also referred to as telehealth 
services, virtual check-ins or eVisits) is not covered out-of-network. Based on this information, we decided that 
the Plans rules for coverage of the telehealth services have not been met. Therefore, we decided that the Plan 
does not have to pay for telehealth services provided on September 6, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the core buildup and resin-based composite filling 
 
You asked the Plan to pre-approve the dental service. You say that this is necessary treatment. The Plan denied 
your request. The Plan says that an appeal review was not performed as the time frame for doing so was 
missed.  
 
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 core buildups 
and fillings 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 requested dental services are supported as medically necessary. Our physician reviewer found the 
provided records in this case document necessity of a crown and build-up of tooth #31 and the requested filling. 
Provided records do not document the requested services are cosmetic or otherwise excluded from the plan's 
coverage 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 the dental services have been met. Therefore, we decided that the Plan has to 
pre-approve the core buildup and resin-based composite filling  
 
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 pre-approve a detachable armrest (E0973), electronic connection 
(E2311), harness (E2313), and expandable controller (E2377). 
 
You asked the Plan to pre-approve a detachable armrest, electronic connection, harness, and expandable 
controller. The Plan denied your request. The Plan says although there are three requested power options (tilt, 
recline and elevating leg rests), there is not a medical need to control these power options through the joystick. 
The Plan also says the description of code E0973 states that this item includes the complete assembly of the 
arm rest. Arm rests and their complete assembly (including any options) are already included with the approved 
power tilt and recline systems. 
 
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 a detachable armrest, electronic 
connection, harness, and expandable controller. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found you have 5 out of 5 
strength in your upper extremities. Our reviewer found that you have adequate upper body strength to manage 
standard power drives. Our physician reviewer also found that the arm rests are included in the power lift 
accessory. 
 
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 detachable armrest, electronic connection, harness, and expandable controller 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a detachable armrest 
(E0973), electronic connection (E2311), harness (E2313), and expandable controller (E2377).
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 requires a place with more one to one 
care for their complex medical needs. The Plan denied your request. The Plan says the enrollee does not meet 
the 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the replacement electrodes (A4556) provided on December 
4, 2022. 
 
You asked the Plan to pay for replacement electrodes. You say that the item should be covered. The Plan 
denied your request. The Plan says this is not a covered item.  

The Plan must follow Medicare rules. Medicare rules say that there should be no billing and there will be no 
separate allowance for replacement electrodes (A4556), conductive paste or gel (A4558), replacement batteries 
(A4630), or a battery charger used with a TENS unit. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of replacement electrodes have not been met. Therefore, we decided that the Plan does not have to 
pay for the replacement electrodes (A4556) provided on December 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revascularization, endovascular, open or percutaneous, 
iliac artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same 
vessel, when performed (37221). 
 
You asked the Plan to pre-approve revascularization, endovascular, open or percutaneous, iliac artery, 
unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, 
when performed. You say that this is medically necessary. The Plan denied your request. The Plan says there is 
no documentation reviewed of imaging studies that confirm occlusive artery disease and the site of the 
blockage to be more than 50% on iliac arteries. There is no documentation of rest pain and/or wound. There is 
no documentation of need for iliac revascularization 
 
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 revascularization, endovascular, open 
or percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement(s), includes 
angioplasty within the same vessel, when performed. Our reviewer says that the requested items/services are 
not considered medically reasonable and necessary in this case. Our physician reviewer found the record 
indicates that the enrollee has aortic atherosclerotic disease. An arteriogram from July 2023, does not 
demonstrate iliac artery disease. The record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of revascularization, endovascular, open or percutaneous, iliac artery, unilateral, 
initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when 
performed have not been met. Therefore, we decided that the Plan does not have to pre-approve 
revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal 
stent placement(s), includes angioplasty within the same vessel, when performed (37221).