Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bridge retainer crown (D6740) for tooth #26, and a pontic 
(D6245) for tooth #24. 
 
You asked the Plan to pay for D6750 and D6245. You say that this dental work is medically necessary. The 
Plan denied your request. The Plan says the x-rays provided do not show that this dental work is medically 
necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers D6750 and 
D6245 when the services are medically necessary and reasonable.  
 
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 D6750 and D6245. Our reviewer says that 
this dental work is not medically necessary. Our physician reviewer found Provided dental x-rays and dental 
records are of inadequate quality and completeness to show necessity of the requested dental procedures. 
Without clearer and more complete x-ray images of the teeth at issue, it cannot be verified that the dental 
procedures at issue in this case meet the Plan's coverage criteria for reasonable and necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of D6750 and D6245 have not been met. Therefore, we decided that the Plan does 
not have to pay for a bridge retainer crown (D6740) for tooth #26, and a pontic (D6245) for tooth #24.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74240 billed for date of service April 28, 
2023.  
 
You asked the Plan to pay for procedure code 74240. You say that the service was billed correctly and should 
be paid. The Plan denied your request. The Plan says payment for code 74240 is bundled into payment for code 
74246. 
 
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 74240 is a column two code to column one code 74246 with a modifier indicator of 0. The column two code is 
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 code 74240 billed for date of service April 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electronic analysis of implanted neurostimulator pulse 
generator/transmitter (95972) and percutaneous implantation of neurostimulator electrode array; peripheral 
nerve (64555). 
 
You asked the Plan to pre-approve peripheral nerve stimulation (PNS) device. You say that the enrollee has 
chronic pain since May 2021, which is on the scale level of 8/10. The enrollee has tried and failed multiple 
injections to help the pain with the last being on June 6, 2023, a shoulder injection with 40% relief. This 
treatment is part of a multi-modal approach to decrease the over-reliance on opioid mediations. The Plan 
denied your request. The Plan says a review of the current medical literature shows that the evidence is 
insufficient to determine that these services are standard medical treatments. 
 
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 peripheral nerve stimulation (PNS) 
device. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has osteoarthritis of the shoulder. She has 
tried multiple injections and has not had relief. The documentation is not clear as to whether or not she has 
done physical therapy (PT) for her shoulder (she has done it for her knee). Imaging suggests she may have a 
tear of the rotator cuff. PT must be trialed before a peripheral nerve stimulator is appropriate. Furthermore, 
PNS is not standard treatment for a rotator cuff tear. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of peripheral nerve stimulation (PNS) device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve electronic analysis of implanted neurostimulator pulse 
generator/transmitter (95972) and percutaneous implantation of neurostimulator electrode array; peripheral 
nerve (64555).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on October 12, 2023, billed 
with procedure code J3490. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says payment is included in the global package. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic, prophylactic, or diagnostic 
intravenous (IV) infusion or injection, other than hydration, is for the administration of substances/drugs. The 
fluid used to administer the drug(s) is incidental hydration and is not separately payable. 
 
We looked at the file and Medicare rules. We find that the billed code is not separately payable as it was billed 
on the same claim as code 62323 without an appropriate modifier. Based on this information, we decided that 
Medicare rules for coverage of the practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on October 12, 2023, billed with procedure 
code J3490.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pitavastatin calcium (J8499). 
 
You asked the Plan to pre-approve Pitavastatin calcium. You say that the drug is medically necessary for 
treatment. The Plan denied your request. The Plan says the medication is not covered as a medical benefit 
under the Plan. 
 
 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Pitavastatin calcium 
(J8499).  
 
Benefits for Pitavastatin calcium may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: 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 not ready to be discharge. You say you 
cannot go to the restroom, taking a bath, and dress without assistance. The Plan denied your request. The Plan 
says the SNF care is not medically necessary and a valid Notice of Medicare Non-Coverage (NOMNC) was 
issued and signed on January 10, 2024. 
 
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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the use of Synvisc or Synvisc-One. 
 You asked the Plan to pre-approve the medication. You say that the requested drug is stocked for the enrollee 
and the preferred drug is not stocked. The Plan denied your request. The Plan says it is not medically necessary 
for the enrollee to use the requested drug over the preferred drug Durolane. 
 
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 medication. Our reviewer says that 
the enrollee does not meet the criteria. Our physician reviewer found the Plan requires a trial of drugs of either 
Durolane, Euflexxa, Supartz and GelSYN-3Forteo before they will approve the requested drug. In this case, the 
enrollee has tried and/or failed the required drug(s). However, there is no documentation provided indicating 
that the Plans required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 
Therefore, the requested drug cannot be 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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the use of Synvisc or Synvisc-One.
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 you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the notes do not show that the enrollee's care 
specifically requires the involvement of a doctor in the field of Rehabilitation Medicine; the notes do not show 
that the enrollee has complex care needs that require a coordinated team approach; the notes do not show that 
the enrollee must have an intensive therapy program (3 hours a day, at least 5 days a week) in order to improve 
self-care functioning.  
 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 and can be 
provided in a lower level of 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 the 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility services provided from July 
15, 2023, through July 29, 2023, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the SNF services. You say that at the time of service the enrollee was residing at 
the location and therefore not responsible to obtain authorization The Plan denied your request. The Plan says 
the enrollee must use network providers to get medical care and services, without proper authorization the 
enrollee will have to pay in full. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. 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 the subsequent nursing facility services provided 
from July 15, 2023, through July 29, 2023, by Madonna Reddington, MD an out-of-network (OON) provider.
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 an IRF admission and services can provide the 
enrollee with the necessary multidisciplinary support, including physical and occupational therapy, to improve 
their functional abilities and restore their independence. The Plan denied your request. The Plan says the 
enrollee's medical and therapy needs could be met in a skilled nursing facility (SNF).  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is medically stable and does not have complex rehabilitation needs that 
require close supervision from a rehabilitation physician with three weekly visits. The enrollee can continue to 
receive 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the MRI provided on October 3, 2023, by an OON provider.  
 
You asked the Plan to pay for the MRI. You say that the MRI was necessary to determine your treatment. The 
Plan denied your request. The Plan says that prior authorization is required. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. 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 the MRI provided on October 3, 2023, by an out- 
OON provider.
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 an IRF admission is required as the enrollee's current 
medical needs cannot safely be met at a lower level of care. The Plan denied your request. The Plan says the 
enrollee does not meet the requirements for an IRF admission.  
 
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 can be 
provided at 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 in 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 pay for the services (99213-25) provided from June 22, 2023, to 
June 30, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the use of modifier -25 
is not supported. 
 
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 the services. Our reviewer says that the use of modifier -25 
with code 99213 is not supported by the records provided. Our reviewer found that the procedure report does 
not include documentation that a significant, separately identifiable service was performed, and therefore, the 
billed services cannot be verified.  
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 the services (99213-25) provided from June 22, 2023, to June 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service August 5, 
2023. 
 You asked the Plan to pay for procedure code 99497. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 99497 is bundled into payment for code 
99223. 
 
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 99497 
is a column II code to column I code 99223. 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 99497 billed for date of service August 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 08, 2023. 
 
You asked the Plan to pay for laboratory services. 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 laboratory services 
provided on August 08, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the catheters (A4352) provided on August 
07, 2023. 
 
You asked the Plan to waive the coinsurance for the catheters (A4352). You say that the cost share is wrong. 
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 Outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay 20% coinsurance for the catheters (A4352). This item/service falls within the 
Outpatient diagnostic tests and therapeutic services and supplies 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 catheters (A4352) provided on August 07, 2023.