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

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
December 6, 2021.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable.  Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service December 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection, expandable controller, and 
expandable controller harness for a replacement power wheelchair (PWC). 
 
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 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that the enrollee has 
adequate strength to manage standard power drive controls. The requested electronic connection, expandable 
controller, and expandable controller harness are therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an electronic connection, expandable controller, and expandable controller harness for a 
replacement power wheelchair (PWC).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180), drugs 
dispensed in office (D9630), and localized delivery of antimicrobial agents (D4381), provided on December 7, 
2022, to December 8, 2022. 
 
You asked the Plan to pay for D0180, D9630, and D4381. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the denied dental services are not covered benefits. 
 
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 pay for a 
comprehensive periodontal evaluation (D0180), drugs dispensed in office (D9630), and localized delivery of 
antimicrobial agents (D4381), provided on December 7, 2022, to December 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
December 7, 2022.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable.  Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service December 7, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from February 11, 2022, 
through August 18, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the acute inpatient hospital care provided 
was not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 these services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that the review indicates that the enrollee was admitted on February 1, 2022 for dehydration with 
hyponatremia. The documentation shows that as of February 6, 2022 his sodium level was adequately 
corrected, and he was no longer receiving intravenous fluids. He had a discharge order for February 6, 2022. 
On February 9, 2022, he had an acute mental status change. There was evidence for a subacute new infarction 
in the left posterior cerebral artery (PCA) distribution and an old infarction in the right PCA distribution. The 
acute infarction was likely responsible for current cognitive changes including memory loss, speech difficulty 
and a right homonymous hemianopsia. The Neurology department did not recommend any change in a 
treatment plan, and he was still pending skilled nursing facility (SNF) placement. In reviewing the case, it 
appears he was no longer receiving an inpatient level of care as of February 10, 2022. He remained an inpatient 
awaiting SNF placement until August 18, 2022. The review has determined that the record showed that at the 
time of the inpatient admission the admitting physician reasonably expected that the enrollee's necessary 
hospital care (including earlier emergency department (ED) and/or observation care) would span two 
midnights. 
  
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 been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from February 11, 2022, through August 18, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an osseous surgery (D4261) provided on November 18, 
2022. 
 
You asked the Plan to pay for D4261. You say that these service should be covered. The Plan denied your 
request. The Plan says D4261 is 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 pay for an 
osseous surgery (D4261) provided on November 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a 2D oral/facial photographic image, crown, core buildup 
services, and an occlusal guard (D0350, D2950, D2740, D9944) provided on January 3, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
 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 pay for a 2D 
oral/facial photographic image, crown, core buildup services, and an occlusal guard (D0350, D2950, D2740, 
D9944) provided on January 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acrylic socket (L5629). 
 
You asked the Plan to pre-approve an acrylic socket. You say that the prosthetic foot prescribed is not an 
advanced foot, but is a standard of care for amputees that have the ability or potential to function at a K2 level. 
The Plan denied your request. The Plan says an acrylic socket cannot be approved with a preparatory socket. 
 
The Plan must follow Medicare rules. Medicare rules say that when an initial below knee prosthesis (L5500) or 
a preparatory below knee prosthesis (L5510, L5520, L5530, L5540) is provided, an acrylic socket (L5629) will 
be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. The record shows that coverage has been approved for a preparatory 
below the knee socket (L5540). Based on this information, we decided that Medicare rules for coverage of an 
acrylic socket have not been met. Therefore, we decided that the Plan does not have to pre-approve an acrylic 
socket (L5629).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed with procedure codes 83698, 83090, 
82607, 82746, 86151, 83701, and 83721 provided on July 16, 2021. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, codes 83698, 
83090, 82607, 82746, 86151, and 83701 are not payable as billed. 
 
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 83721 is a column II code to column I code 
83701 with a modifier indicator of 0. The column II 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 lab services billed with procedure codes 83698, 
83090, 82607, 82746, 86151, 83701, and 83721 provided on July 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 80050 billed for date of service September 
13, 2022. 
 
You asked the Plan to pay for the billed services. You say that the claim was coded correctly. The Plan denied 
your request. The Plan says this code is not covered by Medicare. 
 
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 80050 is a non-covered service. Based on this information, we decided that Medicare 
rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 80050 billed for date of service September 13, 2022.
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 it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the requirements for approval. 
 
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 enrollees nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for hypertensive urgency. Medical problems are stable. There are no complex nursing or 
rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (21089) provided on August 2, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code 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. 
 
In this case, the CPT Code Manual definition of code 21089 is "Unlisted maxillofacial prosthetic procedure". 
 
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 code 21089 is 
not supported by the records provided. Our reviewer found that this date of service mentions the orburator 
prosthesis only. There is no mention of a prosthesis that would be considered an unlisted procedure. 
 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 (21089) provided on August 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular artery embolization with ultrasound access. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has unilateral primary 
osteoarthritis of the left knee with ongoing pain. There is insufficient support in the medical literature 
demonstrating the safety and efficacy of genicular artery embolization in the management of primary 
osteoarthritis of the knee. The services are therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genicular artery embolization with ultrasound access.
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 currently meets IRF admission criteria 
under CMS guidelines. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 
criteria for admission to an Inpatient Rehabilitation Facility. 
 
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. 
 
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 re-evaluation - limited, problem focused (established patient; 
not post-operative visit) (D0170) provided on January 19, 2023. 
 
You asked the Plan to pay for dental services. You say that you needed the requested services in order to know 
how to proceed with your dental plan. The Plan denied your request. The Plan says this service is not covered 
under your Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Re-evaluation - limited, 
problem focused (established patient; not post-operative visit) (D0170) is not covered under the Plan's dental 
benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D0170 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for re-evaluation - 
limited, problem focused (established patient; not post-operative visit) (D0170) provided on January 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Tru Balance 3 static seat (K0108) and an electronic 
connection between wheelchair controller and one power seating system motor (E2310). 
 
You asked the Plan to pre-approve a Tru Balance 3 static seat and an electronic connection. You say that the 
services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that power wheelchair accessories are covered when 
specific 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 a Tru Balance 3 static seat and an 
electronic connection. Our reviewer says that the services are not medically necessary. Our physician reviewer 
found the enrollee is noted to have near normal motor strength in her upper extremities and is independent with 
transfers and performing daily activities. She does not have a history of skin breakdown. She does not require 
power tilt or power tilt and recline and can perform pressure relief adequately. Therefore, the electronic 
connection is also not necessary since this would allow operation of the power seat component. The electronic 
connection (E2310) and true balance seat (K0108) are not medically 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 Tru Balance 3 static seat and an electronic connection have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Tru Balance 3 static seat (K0108) and an 
electronic connection between wheelchair controller and one power seating system motor (E2310).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 9 additional physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy visits. You say that you would like to continue physical 
therapy because it has been helping your legs. You say that you have very tight muscles in your legs and 
physical therapy has helped you walk better.  The Plan denied your request. The Plan says 9 additional physical 
therapy visits are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found that the enrollee has an effective program and home 
exercise program. Therefore, continued input from a skilled therapist is not medically 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 physical therapy visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 9 additional physical therapy visits.