Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97110 billed for dates of service January 3, 
2022, to January 21, 2022. 
 
You asked the Plan to pay for the billed services. You say that the enrollee needed the services. The Plan 
denied your request. The Plan says the services are not payable in the hospital outpatient department. 
 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 looked at the file and the rules. We find that CPT code 97110 was billed with an outpatient hospital facility 
place of service code. Payment may not be made if the service is provided to either a hospital outpatient 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 97110 billed for dates of service 
January 3, 2022, to January 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99285 billed for date of service April 26, 2023. 
 
You asked the Plan to pay for code 99285. You say that the documentation supports the level of care billed. 
The Plan denied your request. The Plan says the service at issue was not billed with the required modifier to 
allow separate payment within the global surgery period. 
 The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM 
services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 51701 
provided on April 26, 2023. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for code 99285 billed for date of service 
April 26, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown-porcelain/ceramic (D2740) for tooth #18. 
 
You asked the Plan to pre-approve the crown. You say that there is a large defective filling, and the x-rays 
show the need for the crown. The Plan denied your request. The Plan says that the request does not meet the 
clinical criteria for a crown. 
 
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 crown 
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 crown. Our reviewer says that the 
service is medically necessary. Our physician reviewer found tooth #18 has a large amalgam filling with a 
fracture structure on the cheek side of the tooth. The tooth also shows fracture lines on the backside of the 
tooth, cheek side, and on the tongue side of the tooth. The amalgam filling is also deteriorating, the margins are 
breaking down, and there is decay around the margins of the amalgam filling. Based on this information, it is 
medically reasonable and necessary for tooth #18 to receive a crown (and core buildup D2950) as this tooth 
needs a full coverage restoration of a crown, or the little remaining tooth structure will continue to fracture and 
can render the tooth unrestorable. When there is not enough tooth structure around a large filling, a full 
coverage crown is recommended to distribute the amount of force on the tooth to decrease risk of fracture. The 
intraoral photos show that there is breakdown of greater than 50% of natural tooth structure which meets the 
criteria for a crown. 
 
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 crown have been met. Therefore, we decided that the Plan has to pre-
approve a crown-porcelain/ceramic (D2740) for tooth #18.  
 
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 pay for the pneumatic compression device and appliance provided 
on April 21, 2023. 
 
You asked the Plan to pay for the pneumatic compression device and appliance. The Plan denied your request. 
The Plan says this is not covered for use outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device and appliance provided on April 21, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Olmesartan-Hydrochlorothiazide. 
 
You asked the Plan to pre-approve the requested medication. The Plan denied your request. The Plan says the 
medication is not covered as a medical benefit under the Plan. 
 
 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Olmesartan-
Hydrochlorothiazide.  
 
Benefits for the requested medication 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: SNF
Decision: Favorable

 
We decided that the Plan has to pay for skilled nursing facility (SNF) services provided from March 22, 2023, 
to April 20, 2023. 
 
You asked the Plan to pay for the SNF services. You say that these services should be paid as the enrollee is 
dual-eligible. The Plan denied your request. The Plan says that the claim was denied because the provider 
needs to submit a corrected bill with a valid Patient Driven Payment Model (PDPM) code.  
 
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 sole basis for its denial is that the provider failed to file a 
claim with a valid PDPM code.  However, the Plan has failed to include a copy of the claim in the case file it 
submitted to us.  Without this claim, we cannot determine if the services were billed correctly or not.  The 
claim is within the Plan's control and should have been submitted to us.  The burden is on the Plan to show why 
its denial is correct.  By failing to provide the single piece of evidence upon which its sole denial rationale is 
based, we find that the Plan has not met this burden. Therefore, we decided that the Plan has to pay for skilled 
nursing facility (SNF) services provided from March 22, 2023, to April 20, 2023.  
 
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 pay for the pneumatic compression device provided on May 4, 2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on May 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral  comprehensive series of radiographic images 
(D0210) provided on March 22, 2023. 
 
You asked the Plan to pay for the dental service. You say that the dental provider did not verify your benefits 
before the services were provided. You also say that they could have contacted the previous provider for the x-
rays. The Plan denied your request. The Plan says your benefit for the requested 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 service was exhausted on date of service April 19, 2021. Therefore, we 
decided that the Plan does not have to pay for the intraoral  comprehensive series of radiographic images 
(D0210) provided on March 22, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the revision/removal of implanted spinal 
neurostimulator. 
 
You asked the Plan to pre-approve the revision/removal of implanted spinal neurostimulator. You say that this 
is medically necessary for you. The Plan denied your request. The Plan says enrollee does not have 
documentation of an implanted spinal neurostimulator. 
 
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 revision/removal of implanted 
spinal neurostimulator. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the record does not indicate that the 
enrollee has a spinal neurostimulator.  
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 revision/removal of implanted spinal neurostimulator have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the revision/removal of implanted spinal 
neurostimulator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power pressure-reducing air mattress (E0277). 
 
You asked the Plan to pre-approve a power pressure-reducing air mattress. You say that the item is medically 
necessary. The Plan denied your request. The Plan says there is no documentation of pressure ulcers, or skin 
graft for a pressure ulcer on the trunk or pelvis within the past 60 days  
 
The Plan follows Medicare rules. Medicare rules say that when the stated coverage criteria for a group 2 
mattress or bed are not met, a claim will be denied as not reasonable and necessary. 
 
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 power pressure-reducing air mattress. 
Our reviewer says that the enrollee does not need this item. Our physician reviewer found there is no 
documentation of pressure ulcers, or skin graft for a pressure ulcer on the trunk or pelvis within the past 60 
days  
 
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 power pressure-reducing air mattress have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a power pressure-reducing air mattress (E0277).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress (E0277). 
 
You asked the Plan to pre-approve a powered pressure-reducing air mattress. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that when the stated coverage criteria for a group 2 
mattress or bed are not met, a claim will be denied as not reasonable and necessary. 
 
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 powered pressure-reducing air 
mattress. Our reviewer says that the enrollee does not need this item. Our physician reviewer found the records 
do not document the presence of any pressure ulcers located on the trunk or pelvis or a history of a 
myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past 60 days. 
 
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 powered pressure-reducing air mattress have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress (E0277).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 12, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says these services are not covered when provided OON. 
 
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 the laboratory services provided on May 12, 2023, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on April 10, 2023. 
 
You asked the Plan to pay for the drug testing. The Plan denied your request. The Plan says the billed services 
are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed. 
 
We looked at the file and Medicare rules. The submitted documentation does not contain a valid physician 
order or lab requisition for the specific testing provided in this case. The documentation also does not contain 
medical records showing the ordering physicians intent that this testing be performed. Based on this 
information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the drug testing provided on April 10, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve self-administered drug, Victoza 18mg/3m. 
 
You asked the Plan to pre-approve the medication. The Plan denied your request. The Plan says the medication 
is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve self-administered drug, 
Victoza 18mg/3m.
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 the enrollee cannot be adequately cared 
for in their current condition at a skilled nursing facility. You would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says admission to an LTACH is not medically necessary.  
 
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 appears 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 transfer to a lower level of care. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to the LTACH is not medically 
necessary as it would not be clinically advantageous.  
 
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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve an MRI of the brain. 
 
You asked the Plan to pre-approve an MRI of the brain. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says that the requested MRI of the brain is not 
medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI of the brain. Our reviewer says 
that the requested imaging is not medically necessary. Our physician reviewer found that the enrollee is noted 
to have a history of chronic migraine headaches. However, they are noted to have had a more acute change in 
the nature and pattern of their headaches. It is readily consistent with standards of care/practice to perform 
imaging studies in such individuals. Such changes are generally indications for which the performance of 
advanced imaging (for headaches) is recommended by guidelines. The requested services can otherwise be said 
to be reasonable and 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 an MRI of the brain. have been met. Therefore, we decided that the Plan has to 
pre-approve an MRI of the brain.  
 
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 bone growth stimulator (E0748). 
 
You asked the Plan to pre-approve a bone growth stimulator. You say that the item is medically necessary. The 
Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion 
of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs 
have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs 
separated by a minimum of 90 days.  
 
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 bone growth stimulator. Our reviewer 
says that the item is not medically necessary. Our physician reviewer found detailed documentation is not 
evident regarding any fusion procedures having been performed on the cervical spine. Additionally, serial x-
rays were not provided for review to demonstrate a lack of fracture healing/progression. The computerized 
tomography  (CT) scan is noted; however, is not provided. Limited published, large-scale, long-term peer-
reviewed literature shows this request to be an effective and/or safe treatment for the noted pathology. No 
compelling rationale is presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception to guidelines. 
 
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 bone growth stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a bone growth stimulator (E0748).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to ESRD provided on January 
24, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you have billed the services 
at issue correctly. 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 ESRD provided on January 24, 2023.