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

 
We decided that the Plan does not have to pay for the exercise equipment provided on April 6, 2023. 
 
You asked the Plan to pay for the services provided. You say that the cost of the unit was less than 
rehabilitation visits. The Plan denied your request. The Plan says the equipment is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pay for the exercise equipment provided on April 6, 2023.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure codes 0042T and 70450 provided on October 20, 2022, by an out-of-network (OON) provider.
You asked the Plan to pay for procedure codes 0042T and 70450. You say that these services were billed correctly and should be paid. The Plan denied your request. The Plan says that code 70450 is bundled in payment for code 70496. Also, code 0042T cannot be paid as it was provided out of network without authorization.
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. 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 70450 is a Column 2 code to Column 1 code 70496. 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. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided procedure code 0042T. 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 procedure codes 0042T and 70450 provided on October 20, 2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional routine transportation trip (A0130) provided 
on May 25, 2023. 
 You asked the Plan to pay for the additional routine transportation trip. You say that the enrollee is completely 
paralyzed on her right side and cannot get to her appointments without a wheelchair transport. The Plan denied 
your request. The Plan says the enrollee has exhausted the 24 one-way trip limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pay for the 
additional transportation trip for the enrollees appointment. Based on this information, we decided that the 
enrollee has exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided 
that the Plan does not have to pay for the additional routine transportation trip (A0130) provided on May 25, 
2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (PVA) for 
vertebral compression fracture (VCF). 
 
You asked the Plan to pre-approve PVA for VCF. You say that it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the requirements for approval. 
 
The Plan follows Medicare rules. Medicare rules say that PVA for VCF may be covered if certain criteria are 
met. 
 
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 PVA for VCF. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the detailed documentation is not evident 
regarding the fractures at T12 and L1 being acute or subacute. Additionally, there is no documentation of a 
progression of the body height loss, greater than 25% vertebral body height loss at both levels, kyphotic 
deformity, or a severe impact on daily activities. Therefore, the enrollee does not meet the indications for this 
procedure.   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PVA for VCF have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous vertebral augmentation (PVA) for vertebral compression fracture (VCF).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve block. 
 
You asked the Plan to pre-approve genicular nerve block. You say that it is medically necessary. The Plan 
denied your request. The Plan says the records did not support the medical necessity for this service. 
 
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 genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is considered experimental/investigational therapy. It is the subject of ongoing 
clinical trials. Therefore, the request is deemed not medically reasonable and 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 genicular nerve block. have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve block.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76882 billed for date of service March 16, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the service was coded correctly. The Plan denied 
your request. The Plan says the diagnosis code is inappropriately coded. 
 
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 76882 is not supported. CPT code 76882 was billed with the LT modifier, indicating 
services performed on the left side. This service was billed with diagnosis code R10.30, defined as lower 
abdominal pain, unspecified. There is a more accurate diagnosis code to describe a condition on the left side. 
Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76882 billed for date of 
service March 16, 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 enrollee requires intensive inpatient rehabilitation 
with daily physician management, continuous specialized rehabilitation nursing, and intensive therapies to 
optimize mobility and strengthening while ensuring the restoration of functional status for a safe and 
sustainable discharge. You also say the enrollee's needs cannot be safely met at lower levels of care. The Plan 
denied your request. The Plan says 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 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the localized delivery of antimicrobial agents via a controlled 
release vehicle into diseased crevicular tissue, per tooth (D4381) provided on May 22, 2023. 
 
You asked the Plan to pay for the localized delivery of antimicrobial agents. You say that you had the left side 
of your mouth scrapped assuming it would also be covered just like in March. You also say that the provider no 
longer works with Medicare and you were not notified of 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. The Plan also says that this service is not a covered expense 
under your dental 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. 
 
The record shows you received the requested dental service from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested service is 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 
the localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per 
tooth (D4381) provided on May 22, 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 this is medically necessary. The Plan denied your 
request. The Plan says this 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 Rehabilitation therapy services can be delivered in a wide variety of settings across 
the care continuum.  Post-acute settings differ in the types of available rehabilitation therapies, intensity of 
therapy, and the level of medical and nursing support.  Acute inpatient rehabilitation facilities are settings were 
complex medical needs and functional needs combine.  The requirements for admission to an inpatient 
rehabilitation facility (IRF) include a need for 24-hour rehabilitation nursing care, a minimum of three 
physician face-to-face visits per week and a minimum of three hours of therapy daily at least five days per 
week (or at least 15 hours over a seven-consecutive day period).  Additionally, an individual requires multiple 
types of therapies one of which should be physical or occupational therapy. 
In this case, the complexity of the members nursing, medical and rehabilitation needs do not require an acute 
rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The member does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. 
The member continues to have a need for skilled therapy with ongoing safety concerns and a potential for 
functional improvement however, the documentation doesnt support that she would meet criteria for 
admission to an acute inpatient rehabilitation facility.  There is no indication that the member would require 
skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a 
physician with at least 3 visits weekly to regain or maintain her functional status.  The member can receive 
further services 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections (ESI). 
 
You asked the Plan to pre-approve epidural steroid injections. You say that it is medically necessary. The Plan 
denied your request. The Plan says it 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 epidural steroid injections. 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 documentation provided indicating that the requested epidural 
steroid injection will be performed using a different approach or medication. The review has determined that 
the items/services at issue in this case are not medically reasonable or 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 epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural steroid injections (ESI).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-covered ambulance mileage (A0888) provided on July 
19, 2023. You asked the Plan to pay for the non-covered ambulance mileage. The Plan denied your request. 
The Plan says you requested to be transferred to a further hospital bypassing the nearest facility. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance transport is covered to the nearest 
appropriate facility equipped to treat the patient. 
 
We looked at the file and Medicare rules. The records show that you were transported to a hospital that was not 
the nearest appropriate facility to obtain necessary care. There was a closer facility that was equipped to 
provide the needed hospital care to treat your condition at the time. Based on this information, we decided that 
Medicare rules for coverage of the ambulance mileage provided on July 19, 2023 have not been met. 
Therefore, we decided that the Plan does not have to pay for non-covered ambulance mileage (A0888) 
provided on July 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service April 4, 
2023.  You asked the Plan to pay for procedure code 88341. You say that the medical records support the frequency of 
services. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88341 is 13. The MAI value for this code is 3. You billed 14 units of this 
code, exceeding the MUE. The medical records did not document any rationale as to why additional units were 
needed for this enrollees care. Based on this information, we decided that Medicare rules for coverage of 
procedure code 88341 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 88341 billed for date of service April 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for periodontal maintenance (D4910) provided 
on May 15, 2023. 
 
You asked the Plan to waive the copayment for periodontal maintenance. You say that this should be covered. 
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 $15 
copayment for periodontal maintenance.  
 
You have been asked to pay $15 copayment for periodontal maintenance. This item/service falls within the 
periodontal maintenance 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 copayment for periodontal 
maintenance (D4910) provided on May 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 87801, 87798, and 87493 for date of service January 
15, 2023. 
 
You asked the Plan to pay for codes 87801, 87798, and 87493. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a GIP test panel must not be unbundled and 
billed as individual components regardless of the fact that the GIP test panel reports multiple individual 
pathogens and/or targets. 
 
We looked at the file and Medicare rules. Review of the file shows that the services were not billed as a 
bundled code/panel. Based on this information, we decided that Medicare rules for coverage of codes 87801, 
87798, and 87493 have not been met. Therefore, we decided that the Plan does not have to pay for codes 
87801, 87798, and 87493 for date of service January 15, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the behavioral health services provided from February 11, 
2023, to February 22, 2023. 
 
You asked the Plan to pay for the behavioral health services. The Plan denied your request. The Plan says the 
clinical information supports that the enrollee is not posing risk of imminent harm to self or others. The Plan 
also says it appears that despite not meeting criteria for inpatient stay, additional time was given for 
consolidation of treatment gains and safe discharge planning. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 the behavioral health services. Our reviewer 
says that the enrollee does not meet the Medicare criteria for continued inpatient psychiatric care beyond 
February 10, 2023. Our physician reviewer found it was not expected this enrollee would improve in a 
reasonable period of time for the dates in question as they did not have suicidal or homicidal ideation, auditory 
or visual hallucinations. The enrollee was compliant with treatment while not showing any acute threats to 
safety. Our reviewer also found that it did not appear medically necessary and reasonable to have psychiatric 
care provided at the acute inpatient level of care rather than 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 the behavioral health services have not been met. Therefore, we decided that the 
Plan does not have to pay for the behavioral health services provided from February 11, 2023, to February 22, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, radiologic examination and chiropractic 
manipulative treatment (CMT) provided on May 11, 2023. 
 
You asked the Plan to pay for an office visit, radiologic examination and chiropractic manipulative treatment 
(CMT). You say that the services should be covered. 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 an office visit, 
radiologic examination and chiropractic manipulative treatment (CMT) provided on May 11, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 2, 2023, to April 
28, 2023. 
 
You asked the Plan to pay for home health services. You say that you are requesting reconsideration for 
payment on this claim. The Plan denied your request. The Plan says the provider did not bill as required by 
Medicare coding regulations. 
 
The Plan follows Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of home health services have not been met. The claim was billed with 
an invalid type of bill. We find the Medicare rule for payment of this March 2, 2023, through April 28, 2023, 
claim has not been met. Therefore, we decided that the Plan does not have to pay for home health services 
provided from March 2, 2023, to April 28, 2023.