Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that based on the enrollee's current condition, functional 
deficits, and multiple comorbidities the enrollee meets IRF criteria. Additionally, the requested IRF services are 
necessary to ensure the restoration of the enrollee's functional status for a safe and sustainable discharge. The 
Plan denied your request. The Plan says the enrollee does not meet all the requirements 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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
the 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 an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the meningococcal vaccines (90620, 90734) provided on 
January 26, 2023. 
 
You asked the Plan to pay for the vaccines. You say that you were charged $444 for a routine Medicare 
physical. You say that there was nothing new except a Meningitis shot. You also say that you were advised by 
a plan representative that it was coded wrong. The Plan denied your request. The Plan says the meningococcal 
vaccines are covered under your Part D benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccines. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccines. 
Therefore, we decided that the Plan does not have to pay for the meningococcal vaccines (90620, 90734) 
provided on January 26, 2023.  
 
Benefits for the vaccines may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement grafts (D7953) and deep sedation 
(D9223). 
 
You asked the Plan to pre-approve the dental services. You say that your provider determined it is medically 
necessary to do a bone replacement to address severe bone loss. You also say you need to be sedated. The Plan 
denied your request. The Plan says the requested services are not covered by Medicare and are not covered by 
your contract with the Plan. 
 
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 bone 
replacement grafts (D7953) and deep sedation (D9223).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extracranial bilateral study (93880) provided on August 
5, 2022. 
 
You asked the Plan to pay for the extracranial bilateral study. You say that this claim is coded correctly, and 
you would like this to be reviewed for payment. The Plan denied your request. The Plan says this service is not 
authorized because it is not a Medicare benefit for the diagnoses listed on the claim. The Plan also says this is 
done for screening purposes. 
 
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 93880 is duplex scan of extracranial arteries; complete 
bilateral study. 
 
We find that CPT code 93880 is not supported in the medical record. Specifically, only certain diagnosis codes 
support necessity of this service. Based on this information, we decided that Medicare rules for coverage of the 
extracranial bilateral study have not been met. Therefore, we decided that the Plan does not have to pay for the 
extracranial bilateral study (93880) provided on August 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit identified with procedure code 99215 for date 
of service July 1, 2022. 
 
You asked the Plan to pay for the office visit. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says this service is not separately payable as billed. 
 
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 find that CPT code 99215 is not supported in the medical record. Specifically, this service was provided 
within the global surgery period of procedure 64633 (Destruction by neurolytic agent, paravertebral facet joint 
nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint). Code 99215 was 
not billed with an appropriate modifier. This means code 99215 is not separately payable as billed. Based on 
this information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, 
we decided that the Plan does not have to pay for the office visit identified with procedure code 99215 for date 
of service July 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment and abutment supported 
porcelain/ceramic crown (D6057, D6058). 
 
You asked the Plan to pre-approve 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 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 with the Plans authorization from March 9, 
2023, to June 14, 2023. Therefore, we decided that the Plan does not have to pre-approve a custom fabricated 
abutment and abutment supported porcelain/ceramic crown (D6057, D6058).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve aquatic therapy. 
 You asked the Plan to pre-approve aquatic therapy. The Plan denied your request. The Plan says the notes do 
not show the mentioned medical condition nor a name of the contracted Physical Therapy (PT) provider who 
would be providing you services and what the PT provider would be medically addressing with the aqua 
therapy. 
 
The Plan must follow Medicare rules. Medicare rules say that outpatient rehabilitation services must relate 
directly and specifically to a written treatment plan. Medicare rules also say that the plan of care must be 
established before treatment is begun. 
 
We looked at the file and Medicare rules. Specifically, there is no evidence of a plan of care for aquatic therapy 
that has been established by a medical provider. Based on this information, we decided that Medicare rules for 
coverage of aquatic therapy have not been met. Therefore, we decided that the Plan does not have to pre-
approve aquatic therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4357 billed for date of service August 1, 
2022, to August 30, 2022. 
 You asked the Plan to pay for procedure code A4357. You say that the provider is a valid durable medical 
equipment provider. The Plan denied your request. The Plan says procedure code A4357 is considered bundled 
and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A4357 has a status indicator of P on the Physician Fee Schedule. This means that 
procedure code A4357 is not separately payable. The National Provider Identification (NPI) information shows 
that the provider can be billed as a durable medical equipment supplier. However, the claim submitted in this 
case was not billed with the appropriate taxonomy code indicating this claim should be billed as a supplier. 
Based on this information, we decided that Medicare rules for coverage of procedure code A4357 have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code A4357 billed for date of 
service August 1, 2022, to August 30, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes A0431-GZ and A0436-GZ provided on August 13, 
2022. 
 
You asked the Plan to pay for codes A0431-GZ and A0436-GZ. You say that this transportation was medically 
necessary. The Plan denied your request. The Plan says codes with the -GZ modifier are automatically denied. 
 
The Plan must follow Medicare rules. Medicare rules say that claim line items with the -GZ modifier are 
automatically denied.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of codes A0431-GZ and A0436-GZ have not been met. Therefore, we decided that the Plan does not 
have to pay for codes A0431-GZ and A0436-GZ provided on August 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on November 16, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
November 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting an expedited 
reconsideration stating the enrollee is not suitable for any lower level of care other than LTACH. The Plan 
denied your request. The Plan says the enrollee does not meet the guidelines for care in 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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The Plan has approved ongoing care in the current care 
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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code K0553 billed for date of service October 31, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed code 
exceeds the maximum allowed amount. 
 
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 K0553 is supply allowance for therapeutic continuous 
glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service. 
 
 We find that CPT code K0553 was billed and paid for by the Plan for date of service October 1, 2022. It is not 
appropriate to bill K0553 twice in one month. 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 K0553 billed for date of service October 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve durable medical equipment to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that the enrollee would face obstacles without the 
pump. The Plan denied your request. The Plan says there are similar services within the 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
durable medical equipment to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee is not a surgical candidate. 
 
The Plan follows Medicare rules. Medicare rules say that spinal cord stimulators are only covered under certain 
medical indications. 
 
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 requested services. Our physician 
reviewer found that the enrollee is being treated for intervertebral disc degeneration of the lumbar region, 
vertebrogenic low back pain, and chronic pain syndrome. Detailed documentation regarding a trial and failure 
of recent, reasonable, comprehensive, less invasive conservative care measures is not evident. The updated 
magnetic resonance imaging (MRI) of the lumbar spine from February 2023, corroborated pathology including 
spinal canal stenosis and disc osteophytes at multiple levels. The documentation does not support the trial and 
failure of any epidural and/or medial branch block procedures to control the low back pain. Moreover, there is 
no indication of any failure of surgical procedures or that he is not a surgical candidate. No compelling 
rationale is presented, or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the requested service is not medically necessary for the enrollee's clinical management. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal cord stimulator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the oxygen equipment and emergency room 
visit provided from October 19, 2022, to December 20, 2022. 
 
You asked the Plan to waive the cost share for the oxygen equipment and emergency room visit. You say that 
you do not understand why these services are not fully covered by Medicare. 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. Your contract with the Plan also clearly says that you must pay a $90 copayment for each emergency room visit. 
 
You have been asked to pay $25.48, which is 20% coinsurance of the allowed amount for the oxygen 
equipment ($127.39 allowed amount x 20% coinsurance = $25.48). This item/service falls within the durable 
medical equipment and related supplies benefit category.  
 
You have also been asked to pay a $90 copayment for the emergency room visit. This item/service falls within 
the emergency care benefit category. You have been asked to pay a total of $115.48 ($25.48 coinsurance + $90 
copayment = $115.48). 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. 
Therefore, we decided that the Plan does not have to waive the cost share for the oxygen equipment and 
emergency room visit provided from October 19, 2022, to December 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on August 3, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you do not agree that the total billed 
amount is not covered by your insurance. 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 August 3, 2022. The Plan 
has paid $32 on May 20, 2022, $70 on June 1, 2022, $2,017 on July 8, 2022, $153 on July 14, 2022, and $1,238 
on August 3, 2022 ($32 + $70 + $2,017 + $153 + 1,238 = $3,510). Therefore, this benefit has been exhausted. 
Therefore, we decided that the Plan does not have to pay more for dental services provided on August 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on August 28, 2022, to 
September 2, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code N17.9, described as acute 
kidney injury (nontraumatic), and secondary diagnosis code J96.01, described as acute respiratory failure with 
hypoxia. 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 inpatient hospital services at the 
DRG originally billed. Our reviewer says that documentation does not support the billed codes. Our physician 
reviewer found there was no documented rise in creatinine of 0.3 and no need for high flow oxygen support, 
bilevel positive airway pressure, or vent support.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on August 28, 2022, to September 2, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
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 you are requesting reconsideration stating you need 
the rehabilitation offered under the SNF. The Plan denied your request. The Plan says criteria for admission to 
a SNF have not been met. 
 
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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do have skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist; however, you do not require 
skilled therapy services on a daily basis. You do not require daily skilled nursing and/or skilled therapy on an 
inpatient basis in a skilled nursing facility (SNF) setting. You do not meet severity of illness or intensity of 
service criteria for an inpatient basis in a skilled nursing facility 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.