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

 
We decided that the Plan does not have to pay for procedure codes 87496, 87532 and 87653 billed for date of 
service January 16, 2023. 
 
You asked the Plan to pay for procedure codes 87496, 87532 and 87653. You say that these services are 
supported as billed. The Plan denied your request. The Plan says these codes are not supported in the medical 
records provided. 
 
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 asked our coder 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 procedure codes 87496, 87532 and 87653. Our reviewer says 
that these codes are not supported in the medical record. Our reviewer found the provided records do not 
contain an order or test results for 87496, 87532 and 87653. There is no evidence that the tests in question were 
performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87496, 87532 and 87653 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 87496, 87532 and 87653 billed for date of 
service January 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a humidifier, heated, used with positive airway pressure 
device (E0562). 
 
You asked the Plan to pre-approve a humidifier. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says included in the monthly rental fee is the ventilator 
and all services/supplies needed for proper operation of that  
device. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The LCD shows that a humidifier is covered and paid separately 
when ordered for use with a respiratory assist device (RAD). Based on this information, we decided that 
Medicare rules for coverage of a humidifier have not been met. Specifically, requesting coverage of additional 
supplies separately constitutes unbundling and is not permitted. Therefore, we decided that the Plan does not 
have to pre-approve a humidifier, heated, used with positive airway pressure device (E0562).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the podiatry office visits provided from 
February 23, 2022, to March 9, 2022. 
 
You asked the Plan to waive the copayments for the podiatry office visits. You say that you were not aware this 
provider was no longer in-network. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees must pay a $25 copayment for each in-network podiatry office visit.  
 
The records show the enrollee is only being charged the in-network copayment for each podiatry office visit. 
The enrollee has been asked to pay a $25 copayment for each podiatry office visit. This item/service falls 
within the podiatry services benefit category. This means that the enrollee has been asked to pay the correct 
amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to 
pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for 
the podiatry office visits provided from February 23, 2022, to March 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service February 6, 
2023. 
 
You asked the Plan to pay for procedure code 81345. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 81345 is bundled into 
payment for code 0089U. 
 
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 81345 
is a column II code to column I code 0089U. 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 81345 billed for date of service February 6, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontic (D6241), core buildup (D2950) and prefabricated 
post and core in addition to crown (D2954). 
 
You asked the Plan to pre-approve pontic, core buildup and prefabricated post and core. You say that this 
should be covered. The Plan denied your request. The Plan says these services are not covered. 
 
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 
pontic (D6241), core buildup (D2950) and prefabricated post and core in addition to crown (D2954).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
February 2, 2023, to February 6, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you would like to 
appeal this service. 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 $345 
copayment per day for days 1-5 of each inpatient hospital stay. Your contract with the Plan also clearly says 
that you then pay a $0 copayment for any additional days of the same inpatient hospital stay. 
 
You have been asked to pay a $345 copayment per day for days 1-4 of the inpatient hospital stay. This 
item/service falls within the inpatient hospital care benefit category. You have not been charged for the day you 
were discharged. You have been asked to pay a total of $1,380 ($345 copayment per day x 4 days = $1,380). 
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 the inpatient hospital stay provided from February 2, 2023, 
to February 6, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on October 8, 2022, to October 
31, 2022. 
 
You asked the Plan to pay for the medical services. You say that this claim should be reprocessed because the 
patient's hospice election ended on October 7, 2022. The Plan denied your request. The Plan says Original 
Medicare is responsible for payment until November 1, 2022. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on October 7, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for medical services 
provided on October 8, 2022, to October 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 84436 and 84480 billed for date of service 
July 5, 2022.  

You asked the Plan to pay for procedure codes 84436 and 84480. You say that these services are supported in 
the medical records. The Plan denied your request. The Plan says payment for codes 84436 and 84480 is 
bundled into payment for codes 84439 and 84481. 
 
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 codes 
84436 and 84480 are column II codes to column I codes 84439 and 84481 respectively, with modifier 
indicators of 0. The column II codes are therefore not payable. 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 codes 84436 
and 84480 billed for date of service July 5, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a right magnetic resonance guided focused ultrasound 
surgery (MRgFUS) (0398T, 70551, and 76498).  
 
You asked the Plan to pre-approve a MRgFUS. You say that the requested service is necessary for the enrollee. 
The Plan denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that MRgFUS unilateral thalamotomy is considered 
medically reasonable and necessary when certain criteria have been 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 a MRgFUS. Our reviewer says that the 
request for MRgFUS is not medically necessary. Our physician reviewer found the provided documentation 
does not support refractory to at least two trials of medical therapy. The reviewer found that the documentation 
does not indicate the presence of a moderate to severe postural or intention tremor, or that the tremor is 
disabling. The reviewer also found that the documentation does not support that the enrollee is not a candidate 
for deep brain stimulation. Therefore, the reviewer found that the requested MRgFUS is 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 a MRgFUS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a right magnetic resonance guided focused ultrasound surgery (MRgFUS) (0398T, 70551, 
and 76498).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 63045 rendered on January 5, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied code cannot be verified. 
 
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 63045 is "Laminectomy, including facetectomy and 
foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], 
[spinal or lateral recess stenosis]), for a single cervical vertebral segment." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found that the operative report does not 
include sufficient documentation to confirm a laminectomy including facetectomy and foraminotomy, per 
coding policy. Additionally, the documentation is insufficient to confirm the modifier billed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 63045 rendered on January 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a harness (2313), an expandable controller (E2377), 
power seat elevation system (E2300), a flat button control (K0108), and calf pads (K0108). 
 
You asked the Plan to pre-approve a harness, an expandable controller, a flat button control, and calf pads. You 
say that you cannot walk on your own. The Plan denied your request. The Plan says the upgraded electronics 
are not medically necessary. The Plan also say that a power seat elevation system is not primarily medical in 
nature and a flat button control and calf pads cannot be requested separately. 
 
The Plan follows Medicare rules. Medicare rules say that upgraded electronics are covered when it is medically 
necessary to control the power options through the joystick. The rules also say that equipment must be primary 
medical in nature. 
 
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 harness and expandable controller. 
Our reviewer says that the requested items are not medically necessary. Our physician reviewer found that you 
have adequate upper body strength to operate the standard power drive controls. 
 
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 harness and expandable controller have not been met. A power seat elevation 
system does not serve a medical purpose. The requested calf pads are included in the approved power 
wheelchair. The requested flat button control is included in the code for an expandable controller. The calf pads 
and flat button control cannot be requested separately. Therefore, we decided that the Plan does not have to 
pre-approve a harness (2313), an expandable controller (E2377), power seat elevation system (E2300), a flat 
button control (K0108), and calf pads (K0108).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve left eye cataract surgery with insertion of aqueous drainage device. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that category III codes are covered when 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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has severe glaucoma and 
cataracts in both eyes. She is on maximum medical therapy with intraocular pressures not at target. She 
recently underwent combine cataract and XEN glaucoma drainage device surgery in the right eye. The 
procedure for the left eye is reasonable and medically necessary based on the submitted documentation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan has to 
pre-approve left eye cataract surgery with insertion of aqueous drainage device.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient mental health care from June 1, 2023, through 
June 5, 2023. 
 
You asked the Plan to pre-approve inpatient mental health care. You say that the stay is medically necessary. 
The Plan denied your request. The Plan says the stay is not medically necessary. 
 
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 pre-approve inpatient mental health care. Our 
physician reviewer found this enrollee does not meet the criteria for treatment in an acute inpatient mental 
health treatment beyond the date in question of June 1, 2023, forward and could have been treated in a lesser 
restrictive setting as the enrollee was not showing any suicidal or homicidal ideation, auditory or visual 
hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant 
while not showing any acute threats to safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient mental health care from June 1, 2023, through June 5, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from September 
9, 2022, to September 30, 2022. 
 
You asked the Plan to pay for SNF care. You say that the services are covered under Medicare guidelines. The 
Plan denied your request. The Plan says services have been approved for September 1, 2022, to September 8, 
2022. Services from September 9, 2022, to September 30, 2022, do not meet the requirements for approval. 
 
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 pay for 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 pay for skilled nursing facility (SNF) care provided from September 9, 2022, to September 30, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar RFA. 
 
You asked the Plan to pre-approve a lumbar RFA. You say that a lumbar RFA is medically necessary. The Plan 
denied your request. The Plan says the member had previous RFA done to the requested spinal levels on 
February 21, 2022. There are no medical notes since the procedure that show the member had 50% 
improvement in pain for six months or provided the member with 50% improvement in ability to perform 
previously painful movements and activities of daily living as compared to baseline measurement using same 
scale that is required for repeat RFA per Medicare policy. 
 
The Plan follows Medicare rules.  
 
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 lumbar RFA. Our reviewer says that 
the requested RFA is not considered medically necessary in this case. Our physician reviewer found that this 
enrollee has chronic low back pain. The enrollee is taking Morphine, Norco, Tizanidine, Lidocaine patch, 
Lyrica and cyclobenzaprine for pain. The enrollee had an RFA of her lumbar facets in 2022. There are no notes 
over the past year detailing the degree and duration of pain relief achieved. Therefore, at this point the request 
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 lumbar RFA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a lumbar RFA.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown (D2740) for tooth #21. 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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 item or service was exhausted. Therefore, we decided that the Plan does 
not have to pre-approve crown (D2740) for tooth #21.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve interim crown for teeth 4 and 5 identified with code 
D2799. 
 
You asked the Plan to pre-approve interim crown for teeth 4 and 5. You say that you disagree with the Plans 
denial. The Plan denied your request. The Plan says the requested services are not a covered benefit. 
 
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 
interim crown for teeth 4 and 5 identified with code D2799.