Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve vertical shock reducing pylon (L5988). 
 
You asked the Plan to pre-approve vertical shock reducing pylon. You say that this is medically necessary. The 
Plan denied your request. The Plan says that this exceeds the members needs. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 vertical shock reducing pylon. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the medical records go above and beyond the documentation standards for a 
function level 3 beneficiary by specifically requesting a prosthesis that will provide a wide range of motion, 
which a vertical shock-reducing pylon as part of a flex-walk type foot would certainly provide. Medicare would 
cover the whole prosthesis  as it has been requested  for this specific beneficiary. The Plan can show no 
specific counter-argument supported by guidelines as to why this exceeds the enrollees medical needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of vertical shock reducing pylon have been met. Therefore, we decided that the 
Plan has to pre-approve vertical shock reducing pylon (L5988).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant supported crown (D6066), surgical placement 
of implant body (D6010), implant surgery (D6011) and anesthesia (D9500). 
 
You asked the Plan to pre-approve implant supported crown, surgical placement of implant body, implant 
surgery and anesthesia. You say that these should be covered. The Plan denied your request. The Plan says 
these are not covered services. 
 
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 
implant supported crown (D6066), surgical placement of implant body (D6010), implant surgery (D6011) and anesthesia (D9500).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0631) provided on November 8, 
2022. 
 
You asked the Plan to pay for a lumbar-sacral orthosis. You say that this should be covered. The Plan denied 
your request. The Plan says Medicare payment for chiropractor services is limited to treatment by means of 
manual manipulation of the spine to correct a subluxation. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for a lumbar-sacral orthosis (L0631) provided on November 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 50 units of procedure code Q9966 provided on December 5, 
2022. 
 
You asked the Plan to pay for 50 units of procedure code Q9966. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the records do not support the 
billing of 50 units of procedure code Q9966. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 50 units of CPT code Q9966 are not supported in the medical record. The medical record only 
supports 1 unit of CPT code Q9966. Based on this information, we decided that Medicare rules for coverage of 
50 units of procedure code Q9966 have not been met. Therefore, we decided that the Plan does not have to pay 
for 50 units of procedure code Q9966 provided on December 5, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the GELSYN-3 (J7328). 
 You asked the Plan to pre-approve the GELSYN-3. You say that the drug is medically necessary. The Plan 
denied your request. The Plan says the step therapy requirement has not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 GELSYN-3. Our reviewer says that 
the member has not met the Plan's step therapy requirement. Our physician reviewer found there is no 
indication that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for 
the enrollee. 
 
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 GELSYN-3 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the GELSYN-3 (J7328).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87631 and 99072 provided on December 5, 
2022. 
 
You asked the Plan to pay for procedure codes 87631 and 99072. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the claim for this molecular 
pathology testing described by procedure code 87631 did not include the required unique identifier. 
Additionally, procedure code 99072 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. Medicare rules also say that providers must 
report services correctly. Providers must report services with the appropriate procedure code. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported for procedure code 87631. Additionally, we find that procedure code 99072 has a status indicator 
of B on the Physicians Fee Schedule. This means that procedure code 99072 is not separately payable. Based 
on this information, we decided that Medicare rules for coverage of procedure codes 87631 and 99072 have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure codes 87631 and 99072 
provided on December 5, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you are requesting reconsideration for the denial of 
a SNF admission. You say the enrollee needs therapy daily to regain their strength and return to assisted living. 
The Plan denied your request. The Plan says the enrollee does not meet the guidelines for services in a SNF. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF services are necessary for the enrollee to regain 
strength and be discharged to home. You are concerned that without IRF services the enrollee's health will 
decline and that may cause other health concerns. The Plan denied your request. The Plan says the requested 
IRF admission 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 that 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 does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy 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 
the 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 an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair and accessories. 
 
You asked the Plan to pre-approve a manual wheelchair. You say that you need a back-up wheelchair in case 
your power wheelchair has an issue. You also say that you cannot walk. The Plan denied your request. The 
Plan says a back-up wheelchair is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that payment is made for only one wheelchair at a 
time. Backup chairs are denied as not reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a manual wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-
approve a manual wheelchair and accessories.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided on June 10, 2022, billed with 
codes 87481, 87500, 87640, 87641, 87651, 87653, and 87798. 
 
You asked the Plan to pay for the laboratory testing billed. You say that these codes should be covered as a 
diagnostic service. 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. The rules say that the laboratory shall report a panel test as one unit of 
service. Individual components should only be billed separately if they are ordered in addition to the panel, are 
medically reasonable and necessary, and are supported by the medical records. The rules also say that modifier 
-59 should only be used to indicate a distinct procedural service. 
 
We looked at the file and Medicare rules. A panel test was performed, and it was not billed with a single panel 
code as required. The medical records provided do not show that the service billed with the -59 modifier is a 
distinct procedural service. Based on this information, we decided that Medicare rules for coverage of the 
genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory testing provided on June 10, 2022, billed with codes 87481, 87500, 87640, 87641, 87651, 87653, 
and 87798.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee can benefit from an acute IRF that 
cannot be accomplished at a lower level of care. The Plan denied your request. The Plan says an IRF admission 
is not medically necessary, and the enrollee's needs can be provided safely in other settings. 
 
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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.
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 you are requesting reconsideration for 
the denial of an LTACH admission based on medical necessity. The Plan denied your request. The Plan says 
criteria for admission to the LTACH have not been met. 
 
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 you appear to be improving with current treatment but are not yet stable for 
transfer. There are no services at the LTACH that you require that are not already available and covered at the 
current facility. Transfer to the LTACH would not be clinically advantageous and completion of treatment at 
the current facility is recommended 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 14, 2022, to 
July 13, 2022. 
 You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider 
their denial of payment. 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 June 14, 2022. The NOA was not received by the Plan until October 3, 
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 June 14, 2022, to July 13, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 7, 2022, to 
August 5, 2022. 
 
You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider 
their denial of payment. 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 July 7, 2022. The NOA was not received by the Plan until November 3, 
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 July 7, 2022, to August 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0003A billed for date of service April 1, 
2022. 
 
You asked the Plan to pay for procedure code 0003A. You say that the charges should be reimbursed. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed. The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 0003A is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 0003A have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 0003A billed for date of service April 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unspecified preventive procedure, by report (D1999) 
provided on January 23, 2023. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this service you 
received. The Plan denied your request. The Plan says this service is not covered under your 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. Unspecified preventive 
procedure, by report (D1999) is not covered under the Plans dental benefits. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D1999 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for unspecified 
preventive procedure, by report (D1999) provided on January 23, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, and the enrollee's needs can be provided safely in other settings. 
 
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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown - porcelain/ceramic tooth #31 (D2740), core 
buildup, including any pins when required tooth #'s 20 and 31 (D2950), and extraction, erupted tooth requiring 
removal of bone and/or sectioning of tooth,  tooth #19 (D7210) provided on October 6, 2022. 
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says your benefit for 
the requested services $3,000 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 date of service October 6, 2022. Additional 
services were received on October 6, 2022 under claim ending in 197850 that also fall under the dental annual 
allowable of $3000.00. Therefore, we decided that the Plan does not have to pay for a crown - 
porcelain/ceramic tooth #31 (D2740), core buildup, including any pins when required tooth #'s 20 and 31 
(D2950), and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth,  tooth #19 
(D7210) provided on October 6, 2022.