Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99215, 99417), Unna boot strapping (29580), 
application of multi-layer compression system (29581), and debridement of an open wound (97597) provided 
on February 21, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the wound care services. You say that you do not agree with the denial. The Plan 
denied your request. The Plan says prior authorization was not obtained. 
 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 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 office visit (99215, 99417), Unna boot 
strapping (29580), application of multi-layer compression system (29581), and debridement of an open wound 
(97597) provided on February 21, 2023, by an out-of-network (OON) provider.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary.  
 
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. The enrollee 
was admitted for a hip fracture after a fall. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. The enrollee does 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. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 87481, 87653, 
87798, and 87801 for date of service April 11, 2023. 
 
You asked the Plan to pay for the laboratory services billed with codes 87481, 87653, 87798, and 87801. You 
say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the services rendered 
are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets. 
 
We looked at the file and Medicare rules. Review of the file shows that the services provided were a panel that 
was billed with separate codes. A panel should be billed as one procedure code. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services billed with codes 87481, 87653, 87798, and 87801 have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
billed with codes 87481, 87653, 87798, and 87801 for date of service April 11, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee has tried and failed 
conservative treatment without relief and this procedure is medically necessary. The Plan denied your request. 
The Plan says that the enrollee does not meet the requirements for approval. 
 
The Plan follows Medicare rules. Medicare rules say that the Intracept procedure may be covered under certain 
circumstances. 
 
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 Intracept procedure. Our reviewer 
says that this procedure is not medically necessary. Our physician reviewer found there is no MRI showing 
only modic changes without facet degenerative joint disease (DJD) or stenosis. The cause of pain is not clear. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) supplies 
coded as A7035, A7034, A7032 A4604, A7046, A7038 and A7039 provided June 23, 2023. 
 
You asked the Plan to pay for the CPAP supplies. You say that you were told by a Plan representative that 
there is no deductible and only out of pocket for both in and out of network. 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. Your 
contract with the Plan says that there is a $400 deductible which applies to Durable medical equipment (DME) 
and related supplies.  
 
The item or service you asked the Plan to pay for falls within the Durable medical equipment (DME) and related supplies benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract 
that there is a $400 deductible which applies to Durable medical equipment (DME) and related supplies. This 
cost sharing is a contractual obligation that had not been met at the time the CPAP supplies was received on 
June 23, 2023. Therefore, we decided that the Plan does not have to pay for the continuous positive airway 
pressure (CPAP) supplies coded as A7035, A7034, A7032 A4604, A7046, A7038 and A7039 provided June 
23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Altru Dx urinary tract infection panel provided on April 
6, 2023, and billed with codes 87481, 87653, 87798, and 87801. 
 
You asked the Plan to pay for the Altru Dx urinary tract infection panel. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the Altru Dx urinary tract infection panel 
have not been met. Therefore, we decided that the Plan does not have to pay for the Altru Dx urinary tract 
infection panel provided on April 6, 2023, and billed with codes 87481, 87653, 87798, and 87801.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on May 30, 2023. 
 
You asked the Plan to pay for laboratory testing. You say that you were not aware this lab was not in-network. 
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 laboratory testing 
provided on May 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the office visit (99204), cone beam scan (76496), 
and impression and custom preparation of an oral surgical splint (21085) provided on July 31, 2023. 
 
You asked the Plan to reimburse you for the outpatient services. You say that you have out-of-network 
coverage for both physician and lab procedures on this claim. The Plan denied your request. The Plan says the 
provider in this case has opted out of Medicare. The Plan also says that payment cannot be made for services 
performed by a provider that has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for 
the office visit (99204), cone beam scan (76496), and impression and custom preparation of an oral surgical 
splint (21085) provided on July 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
March 16, 2023, and billed with codes 87481, 87798, and 87801. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
provided on March 16, 2023, and billed with codes 87481, 87798, and 87801.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral capsulectomy with gel implant exchange with 
tumescent anesthesia. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the request is denied as not reasonable or 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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the record indicates that the enrollee has a history of bilateral reconstruction with 
implant replacement in the setting of breast cancer. The record indicates the enrollee has breast pain but there is 
no documentation that a condition for which coverage is available under the rules is present. The record 
provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the 
requested service. The elements of the coverage criteria are not satisfied. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bilateral capsulectomy with gel implant exchange with tumescent anesthesia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 1, 2023, billed with 
procedure codes 99204, 74240, 74230, 92611, 72040, 70100, and 70310. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim was billed with an inappropriate place of 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that the place of service (POS) code is generally used 
to reflect the actual setting where the beneficiary receives the face-to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the practitioner services provided have not been met. This claim is inappropriately billed with POS 
11, as documentation indicates that there is a more appropriate POS code that should be reported. Therefore, we decided that the Plan does not have to pay for practitioner services provided on May 1, 2023, billed with 
procedure codes 99204, 74240, 74230, 92611, 72040, 70100, and 70310.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve a positron emission tomography (PET) scan. You say that you would like to 
request reconsideration of the denied positron emission tomography (PET) scan and that the services requested 
are medically necessary. The Plan denied your request. The Plan says the criteria for a PET scan have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 a positron emission tomography (PET) 
scan. Our physician reviewer found that a PET scan is not medically necessary and reasonable for the enrollee 
at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a positron emission tomography (PET) scan have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for nurse practitioner services provided on  
May 22, 2023. 
 
You asked the Plan to reimburse you for the nurse practitioner services. You say that the services were 
medically necessary.The Plan denied your request. The Plan says the Plan does not cover services provided to 
members by providers who have opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for 
nurse practitioner services provided on May 22, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a porcelain or ceramic crown (D2740) for teeth numbers 14, 18, 
19 and 3. 
 
You asked the Plan to pre-approve a porcelain or ceramic crown (D2740) for teeth numbers 14, 18, 19 and 3. 
You say that all four of these teeth revealed recurrent decay and have existing fillings covering multiple 
surfaces of each tooth. You also say that restoring these teeth without buildup and crown would seriously 
compromise the prognosis, leaving the enrollee vulnerable to fractures and/or a possible extraction. The Plan 
denied your request. The Plan says that discoloration, deformation, and/or Attrition/Abrasion/Erosion/Loss of 
vertical dimension does not fulfill the criteria for approval for a crown under this 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. The Plan covers a porcelain or 
ceramic crown (D2740) for teeth numbers 14, 18, 19 and 3 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 a porcelain or ceramic crown (D2740) 
for teeth numbers 14, 18, 19 and 3. Our reviewer says that the enrollee meets the criteria for the requested 
service. Our physician reviewer found a review of the documentation indicates that teeth numbers 3, 14, 18, 
and 19 have large defective restorations. Our physician reviewer also found that due to the amount of tooth 
structure to be removed, core buildups have been approved. Our physician reviewer also found that crown 
restorations are medically reasonable and necessary to restore these teeth to proper masticatory function. 
 
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 a porcelain or ceramic crown (D2740) for teeth numbers 14, 18, 19 and 3 have 
been met. Therefore, we decided that the Plan has to pre-approve a porcelain or ceramic crown (D2740) for 
teeth numbers 14, 18, 19 and 3.  
 
  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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee currently meets full IRF criteria. The 
Plan denied your request. The Plan says the enrollee does not meet Medicare guidelines for services in an 
inpatient rehabilitation facillity.  
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical conditions appear stable on outpatient medications with no issues that appear to require a physician's 
evaluation three or more times per week in a hospital setting. The enrollee does require physical therapy and 
occupational therapy services, but the medical records provided do not clarify why the enrollee requires an 
intensive inpatient rehabilitation therapy program. Provided medical records do not support that the intensive 
inpatient rehabilitation therapy program is necessary and that therapy at a lower level of care such as in a 
skilled nursing facility or in the home with home health services is not appropriate for the enrollee. Based on 
the medical records provided, the enrollee would be expected to participate in and benefit from the intensive 
rehabilitation therapy program provided in an inpatient rehabilitation facility; however, the medical records do 
not support a complexity of needs to require an acute inpatient rehabilitation facility over a skilled nursing 
facility or treatment in the home with home health 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Urine PCR panel provided March 17, 2023, billed with 
codes 87150-90-XU x12, 87481-90-XU, 87798-90-XU x12, 87801-90 x3. 
 You asked the Plan to pay for the laboratory testing. You say that kindly review the attached documents and 
process this claim towards possible payment. The Plan denied your request. The Plan says panel testing should 
be billed using one CPT code on the claim. 
 
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 Medicare rules. This was a panel that was not billed with a single panel code as 
required. The standard of care for the evaluation of urinary incontinence is urinalysis with urine culture and 
sensitivity. Based on this information, we decided that Medicare rules for coverage of the laboratory testing 
have not been met. Therefore, we decided that the Plan does not have to pay for the Urine PCR panel provided 
March 17, 2023, billed with codes 87150-90-XU x12, 87481-90-XU, 87798-90-XU x12, 87801-90 x3.