Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft (D7953), core buildup (D2950 
x3), a crown (D2750), a retainer crown (D6750 x2) and a pontic (D6240 x2). 
 
You asked the Plan to pre-approve the dental services. You say that the Plan should cover your dental work as 
you are unable to eat and in pain if this treatment is not performed. The Plan denied your request. The Plan says 
these services are not covered. 
 
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 pre-approve a 
bone replacement graft (D7953), core buildup (D2950 x3), a crown (D2750), a retainer crown (D6750 x2) and 
a pontic (D6240 x2).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for biopsy or excision of lymph nodes (38525) and 
intraoperative identification of sentinel lymph nodes (38900) provided on September 1, 2022. 
 
You asked the Plan to pay for biopsy or excision of lymph nodes (38525) and intraoperative identification of 
sentinel lymph nodes (38900). You say that an assistant surgeon was medically necessary to ensure the safety 
of the patient. You say that an assistant at surgery is not excluded from payment and the codes are eligible for 
reimbursement. The Plan denied your request. The Plan says an assistant surgeon may not be paid for 
procedure code 38525. The Plan also says the add on code cannot be paid since the primary code cannot be 
paid. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. Medicare rules also say that an add-on code is eligible for payment 
only if it is reported with an appropriate primary procedure performed by the same practitioner. 
 
In this case, you billed assistant surgery services for procedure code 38525. The Medicare Fee Schedule 
Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an 
assistant surgeon is not medically necessary for this procedure and will not be paid. In addition, we have 
confirmed that code 38900 is an add-on code that has been billed with an appropriate primary procedure code. 
However, the add-on code cannot be paid if the primary code is not eligible for payment. Based on the claim 
submitted, Medicare billing criteria for procedure codes 38525 and 38900 have not been met. Therefore, we 
decided that the Plan does not have to pay for biopsy or excision of lymph nodes (38525) and intraoperative 
identification of sentinel lymph nodes (38900) provided on September 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 12, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for the denied 
claim. 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 an office visit provided 
on April 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 pressure-reducing support surface (E0277). 
 You asked the Plan to pre-approve Group 2 pressure-reducing support surface. You say that the enrollee has an 
open wound on the back and needs this bed to be comfortable. The Plan denied your request. The Plan says the 
enrollee does not meet criteria for this item. 
 
The Plan follows Medicare rules. Medicare rules state that Group 2 pressure-reducing support surfaces may be 
covered if certain 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 Group 2 pressure-reducing support 
surface. Our reviewer says that the enrollee does not meet criteria for this item. Our physician reviewer found 
the documentation does not show multiple stage 2 ulcers that have failed to heal in the previous month, large 
stage 3 or 4 pressure ulcers, a myocutaneous flap, or skin graft. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Group 2 pressure-reducing support surface have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Group 2 pressure-reducing support surface (E0277).
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 an IRF admission to return to 
her daily activities and regain her independence. The Plan denied your request. The Plan says the enrollee does 
not meet the criteria for an IRF admission.  
 
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 while the enrollee has multiple medical issues, these issues are stable and do not 
complicate care in the current setting. The enrollee does not require treatment by multiple therapies, including 
either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is no 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  
 
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: Favorable

 
We decided that the Plan has to pre-approve a Group 3 power wheelchair with multiple power options. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with multiple power options. You say that this 
is medically necessary for the enrollee. The Plan denied your request. The Plan says that the enrollee does not 
have a medical need for the requested power wheelchair.  
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with multiple power 
options may be covered when certain 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 a Group 3 power wheelchair with 
multiple power options. Our reviewer says that the request for a Group 3 power wheelchair with multiple 
power options is medically necessary. Our physician reviewer found the provided records from an occupational 
therapist (OT) support that the enrollee has significant spasticity which requires tilt and recline to manage. 
Therefore, the reviewer found that the request for a Group 3 power wheelchair with multiple power options is 
medically reasonable and necessary 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 a Group 3 power wheelchair with multiple power options have been met. 
Therefore, we decided that the Plan has to pre-approve a Group 3 power wheelchair with multiple power 
options.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on June 15, 2023. 
 
You asked the Plan to pay for the ambulance services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services were billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance services must be billed with correct 
alpha codes. The first position alpha code equals origin; the second position alpha code equals destination.  
 
We looked at the file and Medicare rules. Review of the file shows that the ambulance services were billed 
with modifier HS. This would mean the ambulance services were provided from the hospital to the scene of the 
accident or acute event. This means the modifier billed with these services is incorrect. Based on this 
information, we decided that Medicare rules for coverage of the ambulance services have not been met. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on June 15, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drugs (J0585) given on September 26, 2022. 
 
You asked the Plan to pay for the drugs. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 drugs. Our reviewer says that the use of code J0585 is not 
supported by the records provided. Our reviewer found that per the medical record, 300 units of Botox were 
given. The National Drug Code (NDC) reported was 00023011450, however this number does not match 
official NDC number for drug given. Therefore, this drug cannot be verified. 
 
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 drugs have not been met. Therefore, we decided that the Plan does not have 
to pay for the drugs (J0585) given on September 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left sacroiliac joint fusion. 
 
You asked the Plan to pre-approve sacroiliac joint fusion. You say that the enrollee would have relief from 
their back pain. The Plan denied your request. The Plan says the medical criteria for this service have not been 
met. 
 
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 sacroiliac joint fusion. 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 sacroiliac joint instability, fracture, or lesion. The patient has systemic 
rheumatoid arthritis. sacroiliac joint fusion for back pain without instability or lesion is experimental. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sacroiliac joint fusion have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a left sacroiliac joint fusion.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on May 16, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for a home visit. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says this provider is out-of-network, and the services could be 
performed in-network. 
 
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 
item/service 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 a home visit provided on May 16, 2023, by an out-
of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fungal polymerase chain reaction (PCR) panel provided on 
May 17, 2022. 
 
You asked the Plan to pay for a fungal PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says the guidelines state that fungal infection of the nail (tinea unguium or 
onychomycosis) can be verified by direct microscopic examination with potassium hydroxide, fungal culture of 
desquamated subungual material, or fungal stain of a nail clippings fixed in formalin. 
 
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 pay for a fungal PCR panel. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the longstanding standard of care for the evaluation of fungus in toenails is the 
performance of both KOH and fungal culture on a toenail specimen. These laboratory tests are inexpensive, 
sensitive, and specific. It is unclear as to why this enrollees toenail required PCR testing as compared to KOH 
and fungal culture. Therefore, the PCR testing of this enrollee's toenail was not medically reasonable or 
necessary at this time. 
 
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 fungal PCR panel have not been met. Therefore, we decided that the Plan does 
not have to pay for a fungal polymerase chain reaction (PCR) panel provided on May 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the polymerase chain reaction (PCR) urine testing provided 
on May 17, 2023. 
 
You asked the Plan to pay for the PCR urine testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services rendered were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 We 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 the PCR urine testing. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation shows that the panel is excessive and not necessary. There is no 
documentation as to why a basic urinalysis with reflex culture is insufficient. Therefore, the enrollee did not 
meet criteria for the services rendered. 
 
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 PCR urine testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the polymerase chain reaction (PCR) urine testing provided on May 17, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from LTACH 
after suffering with a spinal stroke and subsequent paraplegia. The Plan denied your request. The Plan says the 
enrollee is receiving appropriate in-patient acute care and does not require transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care in current acute care setting as provided by 
Health Plan. Our reviewer also found that the documentation does not support that LTACH services are 
medically appropriate at this time.  
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient admission following a left anatomic total 
shoulder arthroplasty (23472). 
 
You asked the Plan to pre-approve an inpatient admission. You say that the surgery is needed because the 
enrollee is in pain. The Plan denied your request. The Plan says there is no documentation provided to support 
the expectation that the enrollee will require a greater than 2 midnight stay. 
 
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 pre-approve an inpatient admission. Our reviewer 
says that the documentation does not support that the criteria for an inpatient admission are met in this case. 
Our physician reviewer found the record does not show that it is reasonable for the physician to expect that the 
enrollee's necessary hospital care will span two midnights with supporting documentation of the patients 
history and comorbidities, signs and symptoms, current medical needs, and risk of an adverse event. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an inpatient admission have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an inpatient admission following a left anatomic total shoulder arthroplasty 
(23472).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on January 4, 2023, billed with 
evaluation and management (EM) code 99223. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 99223 is initial hospital inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded. 
 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 practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the documentation supports an 
appropriate exam, but not an appropriate history or medical decision making of high level. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on January 4, 2023, billed with evaluation and 
management (EM) code 99223.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne Liquid CDx (0239U) provided May 12, 
2022. 
 
You asked the Plan to pay for the laboratory service. You say that FoundationOne Liquid CDx was ordered by 
the treating physician because the test results were needed to help determine the course of treatment for this 
enrollee. The Plan denied your request. The Plan says this expense does not meet this requirement of the Plan 
of benefits. 
 
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 pay for the laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found it is unclear clinical history in the records. There are no medical records from a 
physician. It is unclear why the FoundationOne Liquid study was performed in this case. Only the report of the 
tests is included for review.  
 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the FoundationOne Liquid CDx (0239U) provided May 12, 2022.