Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from IRF services to 
improve overall functional mobility and safety prior to returning home. The Plan denied your request. The Plan 
says the inpatient rehabilitation facility (IRF) services you are requesting do 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 enrollee's 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 lumbar spine surgery. Medical problems are stable. 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the mammogram, breast biopsy, ultrasound, 
an office visit, bioimpedance spectroscopy, therapeutic procedure, outpatient hospital visit, and 
electrocardiogram on April 03, 2023, to June 15, 2023.  
 
You asked the Plan to waive the cost share for the mammogram, breast biopsy, ultrasound, an office visit, 
bioimpedance spectroscopy, therapeutic procedure, outpatient hospital visit, and electrocardiogram. You say 
that you are unsure of the copay amounts owed, and that you have been told different things from the providers 
each time you have called to ask about the charges. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance of the total cost for Medicare-covered therapeutic radiology services. You must pay a $50 
copayment for Medicare-covered diagnostic radiology. You must pay a $50 copayment for Medicare-covered 
diagnostic procedures/tests. You must pay a $225 copayment for Medicare-covered observation services. You 
must pay a $25 copay for Medicare-covered specialist services. The following dates were billed; 
 
For date of service April 3, 2023, you owe a $186 copayment, which is less than the copayment amount. 
For date of service April 7, 2023, you owe a $25 copayment. 
For date of service April 7, 2023, you owe a $25 copayment. 
For date of service April 12, 2023, you owe a $50 copayment. 
For date of service May 5, 2023, you owe a $117.44 copayment, which is less than the copayment amount. 
For date of service May 25, 2023, you owe a $643.06 coinsurance. 
For date of service June 15, 2023, you owe a $8.14 copayment, which is less than the copayment amount. 
 
For all services its, $186 + $25 + $25 + $50 + $117.44 + $643.06 + $8.14 = $1,054.64. Therefore, results in 
the total cost sharing amount of $1,054.64.  
 
You have been asked to pay a $1,054.64 cost share for the mammogram, breast biopsy, ultrasound, an office 
visit, bioimpedance spectroscopy, therapeutic procedure, outpatient hospital visit, and electrocardiogram. This 
item/service falls within the outpatient diagnostic tests and therapeutic services and supplies, outpatient 
hospital observation and physician/practitioner services, including doctors office visits 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 cost share for the mammogram, breast biopsy, ultrasound, an office visit, 
bioimpedance spectroscopy, therapeutic procedure, outpatient hospital visit, and electrocardiogram on April 03, 
2023, to June 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthetic leg with an electronic knee and advanced 
foot feature and other parts, a single axis, fluid swing and stance phase control (L5828), a knee-shin system, 
stance flexion feature, adjustable (L5845), a fluid stance extension, dampening feature (L5848), a 
microprocessor control feature, swing and stance phase (L5856) and an all-lower extremity prosthesis, flex-
walk system (L5981). 
 
You asked the Plan to pre-approve prosthetics. You say that the enrollee reported a desire to ambulate with 
prosthesis. The enrollee discussed the process of fitting a prosthesis and learning to ambulate with a prosthetic 
limb. The Plan denied your request. The Plan says the requested prosthetic parts exceed the enrollee's need. 
 
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 prosthetics. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the physician documentation does not reveal medical reasons that support that this enrollee's 
activities cannot be met with a less advanced mechanical knee or foot. Further, a review of the latest Ottobock 
C leg online, indicates this item has convenience features that exceed the enrollee's medical and functional 
needs such as MyModes and a companion Android app which would allow the enrollee to change modes 
quickly with Bluetooth technology for activities such as biking, golfing, walking, or dancing. These features 
are not a medical necessity and exceed the enrollee's medical and functional need. The enrollee's needs can be 
safely and effectively met with a less complex knee and foot. The enrollee is using a wheelchair, continues to 
be getting rehabilitation in a SNF, and the physician documentation does not support sufficient support that the 
enrollee requires a K3 level advanced knee and foot or a microprocessor knee over a mechanical knee.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prosthetics have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a prosthetic leg with an electronic knee and advanced foot feature and other parts, a single 
axis, fluid swing and stance phase control (L5828), a knee-shin system, stance flexion feature, adjustable 
(L5845), a fluid stance extension, dampening feature (L5848), a microprocessor control feature, swing and 
stance phase (L5856) and an all-lower extremity prosthesis, flex-walk system (L5981).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99285 billed for date of service May 19, 2023. 
 
You asked the Plan to pay for code 99285. You say that the patient was seen two different times. The Plan 
denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. The providers on both claims were the same. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on June 22, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for code 99285 have not been met. Therefore, 
we decided that the Plan does not have to pay for code 99285 billed for date of service May 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the opioid dependence treatment provided on October 31, 
2022, to December 06, 2022. 
 
You asked the Plan to pay for the opioid dependence treatment. You say that you are requesting 
reconsideration for the services provided. 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 the opioid dependence 
treatment provided on October 31, 2022, to December 06, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 73630 billed for date of service July 2, 2023. 
 
You asked the Plan to pay for code 73630. You say that this is a payable code. The Plan denied your request. 
The Plan says this code is not separately payable. 
 
The Plan must follow Medicare rules. The rules say that STV-packaged services are services for which separate 
payment is made only if there is no service with status indicator S, T, or V reported on the same claim. If a 
claim includes a service that is assigned status indicator S, T, or V reported on the same claim as the STV- 
packaged service, the payment for the STV-packaged service is packaged into the payment for the service(s) 
with status indicator S, T, V and no separate payment is made for the STV-packaged service. STV-packaged 
services are assigned status indicator Q1. In this case, the code in dispute has a status indicator of QI, meaning 
that it is a STV-packaged service.  This disputed code was billed on the same claim with a code that has a status indicator of S, T, or V.  This means that the code in dispute in this appeal is not separately payable. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 73630 have not been met. Therefore, we decided that the Plan does not have to pay for code 
73630 billed for date of service July 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93312 billed for date of service February 14, 
2023. 
 You asked the Plan to pay for procedure code 93312. The Plan denied your request. The Plan says payment for 
code 93312 is bundled into payment for code 00562. 
 
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 93312 
is a column II code to column I code 00562. 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 93312 billed for date of 
service February 14, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve crowns (D2740 x 2) for tooth numbers 12 and 13. 
 
You asked the Plan to pre-approve the dental services. You say that your crowns are ten years old and need to 
be replaced due to decay. The Plan denied your request. The Plan says that the criteria for coverage have not 
been met. 
 
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 the dental 
services 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 pre-approve the dental services. Our reviewer says 
that the request is medically necessary. Our physician reviewer found that the existing crowns as seen on the 
provided x-rays exhibit radiolucent areas at the margins. Indicative of the decay process destroying tooth 
structure under the edges of the crowns. As the decay is present in the interproximal area, it would not be 
repairable. The crowns are noted as being over ten years old and do exhibit decay that would require the 
crowns to be replaced. 
 
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 the dental services have been met. Therefore, we decided that the Plan has to 
pre-approve crowns (D2740 x 2) for tooth numbers 12 and 13.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Wound PCR panel provided April 6, 2023, billed with 
codes 87798 x12, 87653-59, 87651-59, 87641-59, 87551-59, 87500-59, 87481-59, 87471-59, G0452-26.  
 
You asked the Plan to pay for the laboratory service. You say that you are asking for reversal of the decision to 
deny these claims reprocess your claims at in network cost and provide retro authorization that is required for further processing. The Plan denied your request. The Plan says this test is not covered. Panel testing should be 
billed using one CPT code on the claim. 
 
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 looked at the file and Medicare rules. This was a panel that was not billed with a single panel code as 
required. Also, per the DEX Diagnostics Exchange Registry, the testing is not covered per the Molecular 
Diagnostics (MolDx) program evaluation. Based on this information, we decided that Medicare rules for 
coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for the Wound PCR panel provided April 6, 2023, billed with codes 87798 x12, 87653-59, 87651-59, 87641-
59, 87551-59, 87500-59, 87481-59, 87471-59, G0452-26.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88173 billed for date of service June 15, 
2023. 
 You asked the Plan to pay for procedure code(s) 88173. The Plan denied your request. The Plan says this code 
is included in the facility payment and is not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88173. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 88173. Based on this information, 
we decided that Medicare rules for coverage of procedure code 88173 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 88173 billed for date of service June 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on October 5, 2022. 
 
You asked the Plan to pay for the urine PCR panel testing. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says the PCR testing is considered unproven and 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 pay for the urine PCR panel testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the standard of care for the evaluation of urinary incontinence is urinalysis with 
urine culture and sensitivity. The PCR testing is considered unproven and not medically necessary. The review 
has determined that the items/services at issue in this case were 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 the urine PCR panel testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing provided on October 5, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 16, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your lab does not have a 
contract with the dialysis facility. The Plan denied your request. The Plan says Medicare does not separately 
pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that you need this procedure to stop your 
severe pain. The Plan denied your request. The Plan says the request 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 the Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you have lumbar disc disease, central spinal stenosis, neural foraminal stenosis, and 
facet arthropathy. You also have radicular symptoms and findings of spinal stenosis and have not undergone a 
psychological evaluation. The Modic changes are at L2-3 and the records do not show an absence of non-
vertebrogenic pathology. Therefore, you do not meet the LCD criteria for coverage. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that you need the requested bed due to 
your arthritis on your hands and knees as well as a risk of falling off the bed. The Plan denied your request. The 
Plan says the requested bed is not covered; the height adjustment feature is a convenience feature. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cardiology consultation to be provided by the 
requested out-of-network provider. 
 
You asked the Plan to pre-approve a cardiology consultation to be provided by the requested out-of-network 
provider. You say that you have established care with this provider since 2002. The Plan denied your request. 
The Plan says the request for out-of-network doctors must be an emergency or not available in-network. There 
are doctors available and can safely be provided in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a 
cardiology consultation to be provided by the requested out-of-network provider.