Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the T6 kyphoplasty. 
 
You asked the Plan to pre-approve the T6 kyphoplasty. You say that the surgery is medically necessary. The 
Plan denied your request. The Plan says the T6 kyphoplasty is not medically necessary. Specifically, there is no 
documentation to support this is an osteoporotic fracture, there is no documentation that there is greater than 
25% vertebral body height loss on advanced imaging, there is no documentation that the enrollee has 
hospitalized with severe pain, and there is no documentation of referral for evaluation of bone mineral density 
(BMD) and osteoporosis education. 
 
The Plan must follow Medicare rules. Medicare rules say that kyphoplasty is covered in patients with an acute 
or subacute osteoporotic vertebral compression fracture (T1-L5), based on symptom onset, and documented by 
advanced imaging, stable to improved pain with greater than 25% vertebral body height reduction, 
hospitalization with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale (VAS) pain score 
greater than 8), and a referral for evaluation of bone mineral density (BMD) and osteoporosis education for 
subsequent treatment as indicated. 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 T6 kyphoplasty. Our reviewer says 
that the T6 kyphoplasty is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the computed tomography (CT) of the thoracic spine as well as the physicians report state 
there is wedge and/or compression deformity fracture without indication that it is osteoporotic. However, it was 
noted to be age-related. This means it is reasonably documented to be a natural age-related osteoporotic 
fracture. However, the documentation provided for review, showed there is not a greater than 25% vertebral 
height reduction, the enrollee was not hospitalized with severe pain and the enrollee was not referred for 
evaluation of BMD, and osteoporosis education. 
 
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 T6 kyphoplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the T6 kyphoplasty.
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 requires inpatient 
rehabilitation level of care.  The Plan denied your request. The Plan says the service requested is not supported 
based on the records received. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan. 
 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a 2D oral/facial photographic image obtained intra-orally or 
extra-orally (D0350), oral hygiene instructions (D1330), and intraoral - periapical each additional radiographic 
image (D0230) provided on February 1, 2023. 
 
You asked the Plan to pay for the dental services. You say that the provider took too many x-rays and that the 
services should be considered a routine part of your plan. The Plan denied your request. The Plan says your 
benefit for the intraoral - periapical each additional radiographic image (D0230) has already been exhausted. 
The Plan also says the 2D oral/facial photographic image (D0350), and oral hygiene instructions (D1330) are 
not covered under the benefit package. 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 intraoral - periapical each additional radiographic image (D0230) was exhausted on 
date of service February 1, 2023. The 2D oral/facial photographic image (D0350), and oral hygiene instructions 
(D1330) are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for a 2D oral/facial photographic image obtained intra-orally or extra-orally (D0350), oral hygiene 
instructions (D1330), and intraoral - periapical each additional radiographic image (D0230) provided on 
February 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and 
appliances (E0667 and E0656). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the enrollee 
does not meet criteria for a pneumatic compression device coded as E0652. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and appliances (E0667 and E0656).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI).  
 
You asked the Plan to pre-approve SSBCI benefits. You say that you do not understand why you have to be in 
the hospital in order to be approved for these benefits. The Plan denied your request. The Plan says the criteria 
for eligibility have not been met.  
 
 
 The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve assisted living facility respite care (custodial care). 
 
You asked the Plan to pre-approve custodial care. You say that the enrollee requires 24-hour care with all 
activities of daily living due to their medical condition. The Plan denied your request. The Plan says custodial 
care is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of custodial care have not been met. Specifically, we find that the services at issue in this case are 
considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve assisted living 
facility respite care (custodial care).
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 services are medically necessary for the 
enrollee's complex medical needs. The Plan denied your request. The Plan says the enrollee does not appear to 
require intensive therapy services only provided in an IRF and their needs could be met at a lower level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service October 31, 
2022. 
 You asked the Plan to pay for procedure code 81345. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says payment for code 81345 is bundled into payment for code 0089U. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 81345 
is a column II code to column I code 0089U. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 81345 billed for date of service October 31, 
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. The Plan denied your request. The Plan says the enrollee does not 
meet the medical necessity criteria for 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 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. 
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy (90837) provided on December 13, 2022. 
 
You asked the Plan to pay for the psychotherapy. You say that this service should be covered. The Plan denied 
your request. The Plan says a Mental Health Counselor is on the list of individuals who are not eligible to 
enroll in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the psychotherapy (90837) provided on 
December 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone graft at time of implant placement (D6104), deep 
sedation/general anesthesia  first 15 minutes (D9222), each subsequent 15 minute increment (D9223), 
therapeutic parenteral drug, single administration (D9610), and surgical placement of implant body: endosteal 
implant (D6010) provided on March 2, 2023. 
 
You asked the Plan to pay for the dental services represented by codes D6104, D9222, D9223, D9610 and 
D6010. The Plan denied your request. The Plan says if you receive a service not listed in the table you will 
have to pay the full cost. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a bone 
graft at time of implant placement (D6104), deep sedation/general anesthesia  first 15 minutes (D9222), each 
subsequent 15 minute increment (D9223), therapeutic parenteral drug, single administration (D9610), and 
surgical placement of implant body: endosteal implant (D6010) provided on March 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the eye exam (92004), eye refraction (92015), scanning 
computerized ophthalmic diagnostic imaging (92134), and eyewear (codes V2020, V2103, and V2702) 
provided on December 1, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay more for the eye exam, eye refraction, diagnostic imaging, and eyewear. You say 
that you only filed one claim and do not understand why your prescription was denied. The Plan denied your 
request. The Plan says these claims were processed correctly. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 
 
We looked at the file and the Plan's rules. Specifically, the record shows that you were correctly charged a 40% 
coinsurance for the OON diagnostic imaging. The record shows that you received a medical eye exam for the 
diagnosis of Puckering of macula, right eye (H35.371). You were also correctly charged a $65 copayment for 
the Medicare covered eye exam, and because this was not a routine exam, the refraction was correctly denied. 
Further, the record shows that your $100 eyewear allowance was applied in full to the eyewear you received on 
this date of service, and your eyewear allowance has been exhausted. Based on this information, we decided 
that the Plan's rules for coverage of the eye exam, eye refraction, diagnostic imaging, frames, single vision 
spherocylinder lenses, and deluxe lens feature have not been met. Therefore, we decided that the Plan does not 
have to pay more for the eye exam (92004), eye refraction (92015), scanning computerized ophthalmic 
diagnostic imaging (92134), and eyewear (codes V2020, V2103, and V2702) provided on December 1, 2022, 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI).  
 
You asked the Plan to pre-approve SSBCI benefits. You say that the services should be covered. The Plan 
denied your request. The Plan says the criteria for eligibility have not been met.  
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not require 
intensive care management. Therefore, we decided that the Plan does not have to pre-approve special 
supplemental benefits for the chronically ill (SSBCI).
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 services are medically necessary. The Plan denied 
your request. The Plan says you do not require an intensive and coordinated interdisciplinary approach to your 
rehabilitation. Services needed may be provided safely in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI).  
 
You asked the Plan to pre-approve SSBCI benefits. You say that you qualified for these benefits last year. You 
also say that you deserve these benefits, which is why you are with this plan. The Plan denied your request. The 
Plan says the criteria for eligibility have not been met.  
 
 
 The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a scooter lift for a vehicle (E1399). 
 
You asked the Plan to pre-approve a scooter lift for a vehicle. You say that the item is medically necessary. The 
Plan denied your request. The Plan says this item does not primarily serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a scooter lift for a vehicle (E1399).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 19, 2022, to 
February 17, 2022. 
 You asked the Plan to pay for the home health services. The Plan denied your request. The Plan says the NOA 
was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 19, 2022. The NOA was not received by the Plan until March 4, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
provided from January 19, 2022, to February 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound covers provided on February 10, 2023. 
 
You asked the Plan to pay for wound covers. You say that these supplies are a separately billable expense that 
do not require authorization. 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 wound covers provided 
on February 10, 2023.