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

 
We decided that the Plan has to pay for periodontal scaling and root planing services provided on September 
21, 2022. 
 
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 that the services denied correctly as they do not 
meet the clinical requirements to be approved. 
 
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 pay for the dental services. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found that the documentation provided meets 
the criteria for coverage for periodontal scaling, four or more teeth per quadrant (D4341) in four quadrants. 
Although local (injectable) anesthesia is recommended, the enrollee has the right to refuse. 
 
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 
pay for periodontal scaling and root planing services provided on September 21, 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: 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 you have had three strokes and require 
the aggressive therapy and care provided at an LTACH. The Plan denied your request. The Plan says the 
enrollee is receiving appropriate in-patient acute care and does not require a 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 that you appear to be improving with current treatment and should only require short-
term additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for a lower level of care. You do not require services at the LTACH that are not already available at 
the current facility. Transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous at this time. Completion of treatment at the current facility is recommended. 
 
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the extraspinal chiropractic manipulative treatment (98943), manual 
therapy (97140), office visit (99213), and the neuromuscular reeducation (97112) provided on December 29, 
2022.  
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the enrollee has exhausted the allowable 
benefit for the services provided in this case.  
 
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 Plans contract states that 30 visits with a licensed chiropractor 
are covered each year for additional services beyond manual manipulation of the spine. The Plan has stated that 
the enrollee has exhausted the allowable benefit for the services provided in this case. The documentation 
submitted in the case file indicates that 35 visits for additional services were rendered by a licensed 
chiropractor. However, the Plan has not provided substantiative evidence that demonstrates these services were 
paid for by the Plan. The Plan has not substantiated their denial; therefore, we must find in your favor. 
Therefore, we decided that the Plan has to pay for the extraspinal chiropractic manipulative treatment (98943), 
manual therapy (97140), office visit (99213), and the neuromuscular reeducation (97112) provided on 
December 29, 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 12 physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the requested services are medically 
necessary. The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has previously been treated with outpatient therapies and 
should be independent with a home exercise program. There is no documentation of a recent injury or decline 
in function. The additional therapy services are not an appropriate duration and frequency for treatment of the 
enrollees medical condition and therefore are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an additional 12 physical therapy (PT) visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator for 9 months (E0466). 
 
You asked the Plan to pre-approve a ventilator for 9 months. 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 must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator for 9 months. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the provided primary source 
documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. You could be treated with a bilevel positive airway pressure (BiPAP) machine with average volume-
assured pressure support (AVAPS) capability and failure of such a device has not been documented. The 
elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
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 ventilator for 9 months have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a ventilator for 9 months (E0466).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on January 23, 2023, billed 
with codes 99204, 74240, 74230, 72040, 70100, and 70310. 
 
You asked the Plan to pay for the radiology services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says this is a non-covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that procedures requiring the administration of a 
substance to the patient or injection of a substance into the patient and/or special manipulation of the patient are 
not covered under portable x-ray provision.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the radiology services provided have not been met. This service provided is a barium swallow 
study and includes the administration of a substance to the patient. Therefore, we decided that the Plan does not 
have to pay for radiological services provided on January 23, 2023, billed with codes 99204, 74240, 74230, 
72040, 70100, and 70310.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a rotator-cuff repair (23412) and shoulder arthroscopy 
(29826). 
 
You asked the Plan to pre-approve a rotator-cuff repair and shoulder arthroscopy. You say that the requested 
procedures are a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested 
services are 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 pre-approve a rotator-cuff repair and shoulder 
arthroscopy. Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that detailed documentation regarding a trial and failure of 
recent, reasonable, comprehensive, less invasive conservative care measures is not evident in the case record, including physical therapy for the right shoulder. 
 
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 rotator-cuff repair and shoulder arthroscopy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a rotator-cuff repair (23412) and shoulder arthroscopy 
(29826).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641, and 87653 billed for 
date of service December 8, 2022. 
 
You asked the Plan to pay for procedure codes 87150, 87481, 87641, and 87653. Plan denied your request. The 
Plan says payment for codes 87150, 87481, 87641, and 87653 are bundled into payments for other codes. The 
Plan says the XU modifier is not supported by medical 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, the CPT Code Manual definition of the billed codes are as follows: 
 
- 87150 Culture typing; identification by nucleic acid (DNA or RNA) probe, amplified probe technique, per 
culture or isolate each organism probed 
- 87481 Candida species, amplified probe technique 
- 87641 Staphylococcus aureus, methicillin resistant, amplified probe technique 
- 87653 Streptococcus, group B, amplified probe technique 
 
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 87150, 87481, 87641, and 87653. Our reviewer says that the 
criteria for coverage has not been met. For code 87150, our reviewer found that an edit exists with CPT 87500 
vancomycin resistance. The service was reported with modifier XU unusual non-overlapping service. After 
careful review of the laboratory report, documentation does not support an unusual non-overlapping service, as 
this documentation was not found in report and therefore cannot be verified. For codes 87481, 87641, and 
87653, an edit exists with CPT 87801 infectious organism detection, multiple organisms; amplified probe 
technique. Service was reported with modifier XU unusual non-overlapping service. After careful review of the 
laboratory report, documentation does not support an unusual non-overlapping service. CPT 87801 includes 
multiple organisms, and therefore this procedure would be included. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 87150, 87481, 87641, and 87653 billed for date of service December 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrical stimulation (code G0283) provided by a 
chiropractor from September 28, 2022, to October 3, 2022. 
 
You asked the Plan to pay for the electrical stimulation services. You say that these services should be covered 
under your Plan. The Plan denied your request. The Plan says electrical stimulation provided by a chiropractor 
is not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for electrical stimulation (code G0283) provided by a chiropractor from 
September 28, 2022, to October 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need rehabilitation to get your strength back and 
therapy to work again. The Plan denied your request. The Plan says the IRF care is not medically necessary, 
and your needs can be met at a lower level of care such as a skilled nursing facility. 
 
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 you were admitted for pulmonary embolism, atrial fibrillation, and myocardial 
infarction. Your medical problems are stable, and there are no complex nursing or rehabilitation needs. You do 
not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty procedure (22514). 
 
You asked the Plan to pre-approve a kyphoplasty. You say that a kyphoplasty is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says a kyphoplasty is 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 pre-approve a kyphoplasty. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee has not been hospitalized due to pain. There is no kyphotic deformity or severe 
limitation on the enrollee's activities of daily living (ADLs). Additionally, there is plausible multifactorial 
thoracolumbar pain denoted on the updated magnetic resonance imaging (MRI) from June 14, 2023. 
 
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 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a kyphoplasty procedure (22514).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the push wheelchair with features. 
 
You asked the Plan to pre-approve the wheelchair. You say that it has been deemed medically necessary for the 
enrollee to receive proper equipment to accommodate their needs. The Plan denied your request. The Plan says 
coverage cannot be provided for equipment used in an institution classified as a SNF.  
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the wheelchair is being requested for use in a SNF or hospital. Therefore, we decided that 
the Plan does not have to pre-approve the push wheelchair with features.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 additional physical therapy visits. 
 
You asked the Plan to pre-approve additional physical therapy visits. You say that the enrollee has had relief 
from the first round of physical therapy with an increase in mobility and quality of life. The Plan denied your 
request. The Plan says 4 additional physical therapy visits are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found that the enrollee has chronic back pain with recent 
exacerbation. However, the provider has not indicated a need for an additional 4 physical therapy visits based 
on the response to therapy. Therefore, additional input from a skilled therapist it is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 4 additional physical therapy visits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiologic examination, knee provided on  
December 12, 2022. 
 
You asked the Plan to pay for radiologic examination, knee. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the Plan is unable to obtain a primary explanation of 
benefits and the Plan has upheld the initial determination until the Plan receives one from the primary insurance 
company. 
 The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has made several 
attempts to obtain the explanation of benefits from the primary insurer. As the secondary insurer, the Plan 
cannot be held responsible for radiologic examination, knee until the primary insurer has denied the claim for 
these services. Therefore, we decided that the Plan does not have to pay for radiologic examination, knee 
provided on December 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device to be provided by an 
out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the OON pneumatic compression device. You say that there is not a 
network provider available within a 50-mile radius that has specialty lymphatic equipment specifically a 
gradient pneumatic compression device with custom segmental attachment sleeves.  The Plan denied your 
request. The Plan says they have network providers who are able to supply the item being requested.  
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic compression device to be provided by an out-of-network (OON) provider.