Persius/hicric huggingface dataset:
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 needs this care to regain function. The 
Plan denied your request. The Plan says the enrollees medical condition does not require IRF services, and care 
can be provided in another setting.  
 
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 can be provided 
in a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach 
to rehabilitation care. The enrollee requires treatment by multiple therapies, including physical therapy and 
occupational therapy, but this can be provided in a lower level of care. There is documentation that there is 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, but the services required can be provided at a lower 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that the requested CGM is medically necessary. The 
Plan denied your request. The Plan says the Medicare criteria was not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our reviewer says that the 
CGM coverage criteria was not met. Our physician reviewer found that the record provided does not document 
that the enrollee is being treated with insulin or has problematic hypoglycemia as defined by the Medicare 
rules. The elements of the coverage criteria are not satisfied. The requested service is not recommended. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
August 23, 2023. 
 
You asked the Plan to pay for the dental services. You say that you believe the Plan should pay for this. 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 out-of-network provider on August 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), harness for upgrade 
to expandable controller (E2313), and electronic connection between wheelchair controller and 2 or more 
power seating system motors (E2311). 
 
You asked the Plan to pre-approve an expandable controller, harness, and electronic connection. You say that 
the services are necessary. The Plan denied your request. The Plan says medical necessity has not been 
established. Therefore, coverage criteria have not been met. 
 
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 an expandable controller, harness, and 
electronic connection. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee's upper extremity functional 
ability as shown by independent in feeding support that this enrollee can control any power options through 
their own switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller, harness, and electronic connection have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377), harness for 
upgrade to expandable controller (E2313), and electronic connection between wheelchair controller and 2 or 
more power seating system motors (E2311).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have waive the coinsurance for Orencia injections provided July 10, 2023, to 
August 7, 2023. 
 
You asked the Plan waive the Orencia injections. You say that you were not told that you would be responsible 
to pay a coinsurance. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part prescription drugs.  
 
You have been asked to pay $641.42 for the Orencia injection provided on July 10, 2023 ($3207.08 x 20% = 
$641.42. You have been asked to pay $649.07 for the Orencia injection provided on July 24, 2023 ($3245.33 x 20% = $649.07). You have been asked to pay $649.07 for the Orencia injection proved on August 7, 2023 
($3245.33 x 20% = $649.07). The total you owe is $1939.56 ($641.42 + $649.07 + $649.07 + $1939.56). These 
items/services fall within the Medicare Part prescription drugs benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
waive the coinsurance for Orencia injections provided July 10, 2023, to August 7, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 90837 billed for date of service May 30, 
2023. 
 
You asked the Plan to pay for procedure code 90837. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the services at issue have not been reported with an 
appropriate modifier. 
 
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 find that CPT code 90837 is not supported. Specifically, code 90837 was billed with the GT modifier. In 
this case, a modifier suitable for payment was not billed. Based on this information, we decided that Medicare 
rules for coverage of procedure code 90837 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 90837 billed for date of service May 30, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services provided on May 12, 2023. 
 
You asked the Plan to pay for surgical assistant services. You say that the proper code was billed for this 
procedure. The Plan denied your request. The Plan says a surgical assistant is not payable for 29848. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 29848. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for 
surgical assistant services have not been met. Therefore, we decided that the Plan does not have to pay for 
surgical assistant services provided on May 12, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the pembrolizumab injections provided on 
May 10, 2022, and May 31, 2022. 
 
You asked the Plan to waive the coinsurance for the injections. You say that you had already met your MOOP 
amount prior to these services. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for in-network drugs covered under Medicare Part B.  
 
You have been asked to pay $2,169.44, which is 20% coinsurance of the allowed amount for the injection 
provided on May 10, 2022 ($10,847.20 allowed amount x 20% = $2,169.44). You have also been asked to pay 
$655.08, which is less than 20% coinsurance due to meeting the $6,900 MOOP amount for the injection 
provided on May 31, 2022. These items/services fall within the Medicare Part B prescription drugs benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the coinsurance for the pembrolizumab injections provided on 
May 10, 2022, and May 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (83520, 87798) provided on July 21, 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 codes billed are not supported in 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. 
 
We find that CPT codes 83520 & 87798 are not supported in the medical record. Specifically, the codes billed 
are Not Otherwise Specified codes, however the lab order does not specify what service these codes represent. 
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, 87798) provided on July 21, 
2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76770 billed for date of service June 28, 
2023. 
 You asked the Plan to pay for procedure code 76770. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 76770 is bundled into payment for code 93976. 
 
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 76770 
is a column II code to column I code 93976. 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 76770 billed for date of service June 28, 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 
October 31, 2022, and billed with codes 87481, 87640, 87652, 87653, and 87798. 
 
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 unbundling of lab codes for PCR panel testing is not appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.   
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing 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 October 31, 2022, 
and billed with codes 87481, 87640, 87652, 87653, and 87798.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone imaging whole body and single photon emission 
computed tomography (SPECT) scan. 
 
You asked the Plan to pre-approve the SPECT scans. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the services are 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 SPECT scans. Our reviewer says 
that the SPECT scans are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the received documentation and given the relatively stable trend and prostate specific 
antigen (PSA) being below 2, a bone scan is not indicated at this time. The services cannot be approved. 
 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 SPECT scans have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a bone imaging whole body and single photon emission computed tomography 
(SPECT) scan.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a transforaminal epidural steroid injection (TFESI), second level 
(64484). 
 
You asked the Plan to pre-approve a TFESI at the second level. You say that the records support that the 
coverage criteria have been met. The Plan denied your request. The Plan says that a TFESI is not covered for 
the sacrum spine. 
 
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 a TFESI at the second level. Our 
reviewer says that the requested TFESI at the second level is considered medically reasonable and necessary in 
this case. Our physician reviewer found the provided records show that the enrollee has had prior spinal 
surgery at both L4-L5 and L5-S1 and has failed back surgery syndrome for which a Spinal Cord Stimulator is 
in place. Therefore, the reviewer found that the requested TFESI at the second level is medically reasonable 
and necessary in this case. 
 
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 TFESI at the second level have been met. Therefore, we decided that the Plan 
has to pre-approve a transforaminal epidural steroid injection (TFESI), second level (64484).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the digital analysis of an electroencephalogram (95957) 
provided on August 8, 2023. 
 
You asked the Plan to pay for the digital analysis of an electroencephalogram. You say that this was medically 
necessary. The Plan denied your request. The Plan says this was not billed with an electroencephalogram. 
 
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 95957 is digital analysis of electroencephalogram (EEG) 
(eg, for epileptic spike analysis). 
 
We find that CPT code 95957 is not supported in the medical record. Specifically, the submitted records do not 
include documentation of digital analysis. Based on this information, we decided that Medicare rules for 
coverage of the digital analysis of an electroencephalogram have not been met. Therefore, we decided that the 
Plan does not have to pay for the digital analysis of an electroencephalogram (95957) provided on August 8, 
2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 home health physical therapy visits (G0151) and 2 
home health occupational visits (G0152). 
 
You asked the Plan to pre-approve home health services. You say that the services are necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee is 
not shown to have home health occupational therapy needs. The enrollee is functioning at a level commiserate 
with a lower level of care. As such, the requested number of home health occupational therapy visits is not 
medically necessary or reasonable. The health plan did approve five visits. No skilled nursing records are 
identified. The Notice of Denial of Medical Coverage only addresses occupational therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 6 home health physical therapy visits (G0151) and 2 home health occupational 
visits (G0152).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fixed partial denture (D9120), surgical implants 
(D6010 x2) and an abutment supported cast metal crown (D6064 x2). 
 
You asked the Plan to pre-approve the dental services. You say that this should be approved because the Plan 
would have paid if it was an in-network provider. You say you want the services rendered now due to other 
dental work was completed and this is needed. The Plan denied your request. The Plan says only dental codes 
listed will be covered. The Plan also says services must be performed by a participating general dentist. 
 
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 pre-approve a 
fixed partial denture (D9120), surgical implants (D6010 x2) and an abutment supported cast metal crown 
(D6064 x2).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant Reveal testing (81479) provided on June 19, 
2023. 
 
You asked the Plan to pay for the Guardant Reveal testing. You say that this testing was medically necessary.  
The Plan denied your request. The Plan says this test is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests such as the 
Guardant Reveal are subject to the MolDX application, assessment, and approval process. 
 We looked at the file and Medicare rules. We find that the Guardant Reveal test has not been approved for 
coverage based on information in the DEX Diagnostic Exchange. Based on this information, we decided that 
Medicare rules for coverage of the Guardant Reveal testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the Guardant Reveal testing (81479) provided on June 19, 2023.