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

 
We decided that the Plan does not have to pay for the lab testing billed for date of service Jul 31, 2023. 
 
You asked the Plan to pay for the billed testing. The Plan denied your request. The Plan says one code must be 
submitted for the panel. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 The file shows that a respiratory panel test was billed with multiple codes, including code 87798. We find that 
the respiratory panel test was not billed with a single code as required. Based on this information, we decided 
that Medicare rules for coverage of the billed testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the lab testing billed for date of service Jul 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (83520) provided on January 23, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the billed code is not supported by the 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 code 83520 is Immunoassay for analyte other than infectious 
agent antibody or infectious agent antigen. 
 
We find that CPT code 83520 is not supported in the medical record. Specifically, the code billed is a not 
otherwise specified code, however records do not detail what the test was for. Based on this information, we 
decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the 
Plan does not have to pay for lab services (83520) provided on January 23, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional physical therapy visits 
 
You asked the Plan to pre-approve physical therapy visits. You say that these services are medically necessary 
for the enrollee. The Plan denied your request. The Plan says these 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 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 unique skills of a professional therapist are not 
required to safely and effectively provide further treatment. The enrollee has had ample sessions approved to be 
versed in a home exercise program. Therefore, the requested additional skilled therapy sessions 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 physical therapy visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 6 additional physical therapy visits
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system.  
 
  You asked the Plan to pre-approve a home ventilator system. You say that based on the patients current 
diagnosis and lab results they are more than qualified to have a non-invasive ventilator approved. The Plan 
denied your request. The Plan says a home ventilator is not medically necessary for this patient because their 
needs can be met with an alternative device such as a BiPAP device with average volume-assured pressure 
support (AVAPS).  
 
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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy 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 home ventilator system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that while the 
patient has a diagnosis of COPD, there is no diagnosis of thoracic restrictive disease or neuromuscular disease. 
There are no pulmonary functions tests to confirm airways obstruction or assess severity. Also, there is no 
evidence to support chronic carbon dioxide retention, and if the patient were to have chronic carbon dioxide 
retention, they may benefit from a BiPAP with AVAPS during sleep. Additionally, Medicare does not cover a 
home ventilator when used at settings that can be provided with a BiPAP. 
 
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 home ventilator system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says the request 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 the Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging showing only modic changes without facet 
degenerative joint disease or foraminal 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 (64628).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the trimming of fingernails or toenails (11719) provided on 
June 1, 2023. 
 
You asked the Plan to pay for the routine foot care. You say that you did not know this was routine. You also 
say that this has been covered in the past. The Plan denied your request. The Plan says routine foot care is not 
covered. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records do not show that any of these conditions are present. The services you are asking the Plan to pay for 
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the 
routine foot care have not been met. Therefore, we decided that the Plan does not have to pay for the trimming 
of fingernails or toenails (11719) provided on June 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve general anesthesia (D9223, D9222). 
 
You asked the Plan to pre-approve general anesthesia. You say that this should be covered. The Plan denied 
your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
general anesthesia (D9223, D9222).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve liver transplant services. 
 
You asked the Plan to pre-approve liver transplant services. You say that the enrollee was declined by an in-
network facility for transplant evaluation. The Plan denied your request. The Plan says that this provider is not 
certified for liver transplant. 
 
The Plan must follow Medicare rules. Medicare rules say that adult liver transplant services may be covered 
when performed by a facility that is certified by Medicare.  
 
We looked at the file and Medicare rules. The sole basis of the Plans denial is that the requested provider is 
not Medicare certified to perform adult liver transplant services. However, this provider has a certified liver 
transplant program and an active membership in the Organ Procurement & Transplantation Network (OPTN). 
The Plan did not provide any other rationale to support a denial of authorization for this service. Based on this 
information, we decided that Medicare rules for coverage of liver transplant services have been met. Therefore, 
we decided that the Plan has to pre-approve liver transplant services.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Arexvy injection. 
 
You asked the Plan to pre-approve an Arexvy injection. You say that you would like to appeal the denial for 
the Arexvy injection as Respiratory Syncytial Virus (RSV) is going around. You also say that you are a 
diabetic with respiratory/digestion issues, asthma, have had COVID-19 a few times and you think this injection 
will benefit you. The Plan denied your request. The Plan says as RSV vaccines Arexvy and Abrysvo are only 
indicated for the prevention of respiratory syncytial virus (RSV) and not for the treatment of RSV, it is 
therefore covered as a Part D benefit. The Plan also says that your plan does not include Part D coverage. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide an Arexvy injection. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to an Arexvy 
injection. Therefore, we decided that the Plan does not have to pre-approve an Arexvy injection.  
 Benefits for an Arexvy injection may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intravenous moderate (conscious) sedation/analgesia- first 15 
minutes (D9239) and intravenous moderate (conscious) sedation/analgesia - each subsequent 15 minute 
increment (D9243) and gingival flap procedure, including root planing (D4241) provided on July 3, 2023. 
 
  You asked the Plan to pay for intravenous moderate (conscious) sedation/analgesia- first 15 minutes (D9239) 
and intravenous moderate (conscious) sedation/analgesia - each subsequent 15 minute increment (D9243) and 
gingival flap procedure, including root planing (D4241). You say that the periodontist work was a result of the 
fall on January 31, 2023. The Plan denied your request. The Plan says these services are not payable in 
conjunction with the services performed and/or reasons documented. 
 
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 intravenous 
moderate (conscious) sedation/analgesia- first 15 minutes (D9239) and intravenous moderate (conscious) 
sedation/analgesia - each subsequent 15 minute increment (D9243) when the services are medically necessary 
and reasonable. Gingival flap procedure, including root planing (D4241) is not a covered benefit on your Plan. 
 
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 intravenous moderate (conscious) 
sedation/analgesia- first 15 minutes (D9239) and intravenous moderate (conscious) sedation/analgesia - each 
subsequent 15 minute increment (D9243) and gingival flap procedure, including root planing (D4241). Our 
reviewer says that due to lack of information provided, the requested services are not medically reasonable or 
necessary. Our physician reviewer found clinical notes included of a visit made to the dental provider after the 
fall state on February 9, 2023, stated that pock depths are within normal limits. Our physician reviewer also 
found that there were no recommendations by the dental provider in the clinical notes that support the 
procedures in question. 
 
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 intravenous moderate (conscious) sedation/analgesia- first 15 minutes (D9239) 
and intravenous moderate (conscious) sedation/analgesia - each subsequent 15 minute increment (D9243) and 
gingival flap procedure, including root planing (D4241) have not been met. Therefore, we decided that the Plan 
does not have to pay for intravenous moderate (conscious) sedation/analgesia- first 15 minutes (D9239) and 
intravenous moderate (conscious) sedation/analgesia - each subsequent 15 minute increment (D9243) and 
gingival flap procedure, including root planing (D4241) provided on July 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam (D0364), an apicoectomy (D3425) for tooth 
#30, a retrograde filling (D3430) for tooth #30, and a non-intravenous sedation (D9248) provided on June 13, 
2023, and June 28, 2023. 
 
You asked the Plan to pay for the dental services. You say that the dental services were medically necessary, 
and they should be eligible for reimbursement. The Plan denied your request. The Plan says the denial of 
payment for these services is correct, because the cone beam, an apicoectomy, a retrograde filling, and a non-
intravenous sedation are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 cone 
beam (D0364), an apicoectomy (D3425) for tooth #30, a retrograde filling (D3430) for tooth #30, and a non-
intravenous sedation (D9248) provided on June 13, 2023, and June 28, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Alfuzosin. 
 
You asked the Plan to pre-approve the medication. You say that the drug is medically necessary. 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 Alfuzosin.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 billed for date of service May 27, 
2023. 
 
You asked the Plan to pay for the billed service. You say that the chart was coded correctly. The Plan denied 
your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that certain diagnosis codes have an Excludes1 note which lists 
other diagnosis codes with which they cannot be reported.  In this case, we have confirmed that diagnosis code group R11 has an Excludes1 note in relation to F50.89. 
This means that diagnosis codes R11.0 and F50.89 cannot be reported together. Based on this information, we 
decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99284 billed for date of service May 27, 2023.
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 to help the 
enrollee recover in a reasonable amount of time. The Plan denied your request. The Plan says the enrollee's 
medical condition requires further evaluation and treatment in the acute care hospital.  
 
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, including either 
physical or occupational therapy, and an intensive rehabilitation therapy program. Therapy documentation 
dated November 8, 2023, indicated that the enrollee required minimal assistance with bed mobility, transfers, 
and gait. The enrollee requires sit up assistance with upper body daily activities and moderate assistance with 
lower extremity daily activities. The enrollee is touch down weight bearing in the left lower extremity. The 
enrollee has had a decline from their baseline level of function and may benefit from occupational and physical 
therapies as well as supervision and assistance, but they do not require the intensity of therapies provided on 
acute inpatient rehabilitation. Therefore, the acute inpatient rehabilitation admission 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 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 pay for the pontic - porcelain/ceramic (D6245), custom fabricated 
abutment  includes placement (D6057), and abutment supported porcelain/ceramic crown (D6068), provided 
on June 29, 2023. 
 
You asked the Plan to pay for the dental services. You say that these services should be paid. The Plan denied 
your request. The Plan says your benefit for the requested item or service $2,000 dollar limit was met. 
 
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 services was exhausted on dates of service January 12, 2023, February 21, 
2023, and March 1, 2023. Therefore, we decided that the Plan does not have to pay for the pontic - 
porcelain/ceramic (D6245), custom fabricated abutment  includes placement (D6057), and abutment 
supported porcelain/ceramic crown (D6068), provided on June 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an OON provider on July 5, 
2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says the dental services were received from an out-of-network provider and are not covered 
by your supplemental benefits.  
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided by an OON provider on July 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  otolaryngology services to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve  otolaryngology services. You say that you have seen this provider in the 
past and would like to see them again. The Plan denied your request. The Plan says OON providers are 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 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  
otolaryngology services to be provided by an OON provider.