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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is medically stable and does not need physician's supervision 3 times a 
week in an IRF. There are no acute rehabilitation nursing needs identified or documented. At the current level 
of function, the enrollee does not need intensive therapies consisting of at least 3 hours of therapy per day at 
least 5 days per week with a multidisciplinary approach in an IRF. While the enrollee may benefit from 
continued physical therapy, speech therapy, and occupational therapy, the enrollee's rehabilitation needs can be 
safely provided in a lower intensity and alternate 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on October 6, 2022, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for laboratory services. You say that the facility is contracted with the plan, and no 
authorization is required. The Plan denied your request. The Plan says an authorization was not submitted prior 
to services rendered. 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 laboratory services provided on October 6, 2022, 
by 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 the services are medically necessary. The Plan 
denied your request. The Plan says the enrollee can receive care at a lower level of care such as a skilled 
nursing 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 enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for 

You asked the Plan to pay for ambulance services. You say that the enrollee was not enrolled in hospice at the time of service. The Plan denied your request. The Plan says Original Medicare is responsible for payment.

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 January 19, 2023. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for ambulance services provided on January 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99222 billed for date of service December 20, 2022. 
 
You asked the Plan to pay for code 99222. You say that the services met all of the requirements for the level of 
service billed. The Plan denied your request. The Plan says code 99222 is not supported by the medical record. 
The records don't support a comprehensive history. 
 
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 99222 is Initial Hospital Care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of moderate complexity. 
 
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 code 99222. Our reviewer says that code 99222 is not supported by the medical records. Our reviewer found the enrollee was a then, 83 year old male with a history 
of hypertension, chronic kidney disease, and atrial fibrillation who was admitted on December 20, 2022, with 
weakness and symptomatic anemia. The review indicates that there was no documentation of a comprehensive 
history. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99222 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99222 billed for date of service December 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a CT scan of the head or brain. 
 You asked the Plan to pay for a CT scan of the head or brain. You say that the claim should be reprocessed. 
The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
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 July 23, 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 a CT scan of the head or 
brain.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation-per site 
(D7953) provided on March 15, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service 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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bone 
replacement graft for ridge preservation-per site (D7953) provided on March 15, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from July 31, 2022, to August 
29, 2022. 
 You asked the Plan to pay for the home health services. You say that the claim complies with Medicare billing 
guidelines. The Plan denied your request. The Plan says the NOA was not received timely. As such, this final 
claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is July 31, 2022. The NOA was not received by the Plan until September 2, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from July 31, 2022, to August 29, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 12, 2023, to 
February 10, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you have submitted the required 
NOA. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 12, 2023, to 
February 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140), 
intraoral - complete series of radiographic images (D0210), periodontal scaling and root planing - four or more 
teeth per quadrant periodontal scaling and root planing - four or more teeth per quadrant (D4341), periodontal 
scaling and root planing - one to three teeth per quadrant (D4342), mandibular partial denture  resin base 
(including, retentive/clasping materials, rests, and teeth) (D5212), and interim partial denture (including 
retentive/clasping materials, rests, and teeth), mandibular (D5821)  provided on August 2, 2022, to August 10, 
2022. 
 
You asked the Plan to pay for the dental services represented by codes D0140, D0210, D4341, D4342, D5212 
and D5821. You say that you are requesting your claim to be reviewed.  
 You also say that this concern was a needed medical procedure concerning your mouth, jawbone and health 
which was located in your mouth and jawbone area and not for a regular dental procedure. The Plan denied 
your request. The Plan says you do not have supplemental coverage for these dental codes. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation - 
problem focused (D0140), intraoral - complete series of radiographic images (D0210), periodontal scaling and 
root planing - four or more teeth per quadrant periodontal scaling and root planing - four or more teeth per 
quadrant (D4341), periodontal scaling and root planing - one to three teeth per quadrant (D4342), mandibular 
partial denture  resin base (including, retentive/clasping materials, rests, and teeth) (D5212), and interim 
partial denture (including retentive/clasping materials, rests, and teeth), mandibular (D5821)  provided on 
August 2, 2022, to August 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prefabricated abutment - includes modification and 
placement (D6056), abutment supported porcelain/ceramic crown (D6058), and pontic (D6245). 
 
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 prefabricated abutment - includes modification and placement (D6056), abutment 
supported porcelain/ceramic crown (D6058), and pontic (D6245).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant supported porcelain/ceramic crown for teeth 
#19, #29, #30 (D6065) and prefabricated abutment - includes placement tooth #19 (D6056). 
 
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 implant supported porcelain/ceramic crown for teeth #19, #29, #30 (D6065) and 
prefabricated abutment - includes placement tooth #19 (D6056).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a suction assisted lipectomy and excision excessive skin 
and subcutaneous tissue (15877,15847,15830). 
 
You asked the Plan to pre-approve a suction assisted lipectomy and excision excessive skin and subcutaneous 
tissue. You say that the service is medically necessary. The Plan denied your request. The Plan says the service 
is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 suction assisted lipectomy and 
excision excessive skin and subcutaneous tissue. Our reviewer says that the service is not medically necessary. 
Our reviewer found the documentation, including the physical examination and photographs, do not support that the enrollee in this case has significant functional impairment, such as persistent cellulitis, abscess, or skin 
ulceration that has been refractory to medical therapy. 
 
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 suction assisted lipectomy and excision excessive skin and subcutaneous 
tissue have not been met. Therefore, we decided that the Plan does not have to pre-approve a suction assisted 
lipectomy and excision excessive skin and subcutaneous tissue (15877,15847,15830).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve adding bone at one mouth site (D4263). 
 
You asked the Plan to pre-approve adding bone at one mouth site. You say that this should be covered. The 
Plan denied your request. The Plan says this is not a covered service. 
 
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 
adding bone at one mouth site (D4263).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a CTA scan of the abdominal arteries. 
 
You asked the Plan to pre-approve a CTA scan of the abdominal arteries. You say that the CTA is needed to 
get further images to determine for planning a bypass surgery if needed. The Plan denied your request. The 
Plan says that a CTA scan of the abdominal arteries is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 a CTA scan of the abdominal arteries. 
Our reviewer says that a CTA scan of the abdominal arteries is medically necessary. Our physician reviewer 
found that the computed tomography of the abdomen and pelvis was not done as a CTA scan. However, there 
was documentation of a severe atherosclerotic disease and the request for a CTA of the aorta and runoff is 
entirely appropriate to determine if the enrollee is a candidate for bypass surgery. Also, to wait until a ischemic 
disease to manifest itself is not appropriate without having knowledge of the enrollees degree of vascular 
insufficiency. Therefore, the requested CTA scan of the aorta and runoff is reasonable and appropriate. 
 
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 CTA scan of the abdominal arteries have been met. Therefore, we decided that 
the Plan has to pre-approve a CTA scan of the abdominal arteries.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77012 billed for date of service October 5, 
2022. 
 
You asked the Plan to pay for procedure code 77012. 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 77012 is bundled into 
payment for code 22511. 
 
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 77012 
is a column II code to column I code 22511. This claim has not been billed with an appropriate modifier to 
bypass the edit. The medical records provided do not show that the service billed with the -59 modifier is a 
distinct procedural service. 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 77012 billed for date of service 
October 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre 3 Sensors 
 
You asked the Plan to pre-approve Freestyle Libre 3 Sensors. You say that the records provided support the need for the requested type of device. You say that if you are sleeping and your sugars are low you will be able to get notified right away with the requested device. The Plan denied your request. The Plan says the Freestyle Libre 3 is not currently eligible for Medicare reimbursement as it does not display glucose on a receiver or insulin infusion pump, so it does not meet the Medicare definition of durable medical equipment.
 
The Plan must follow Medicare rules. Medicare rules say that a non-adjunctive continuous glucose monitor 
(CGM) must be billed with code E2103. The rules also say that only devices reviewed by the PDAC and assigned code E2103 may be billed using this code.  
 
We looked at the file and Medicare rules. The request at issue is for the Freestyle Libre 3 non-adjunctive CGM. 
However, this device has not been reviewed by the PDAC and has not been assigned code E2103. As such, this 
non-adjunctive CGM device is not eligible for coverage at this time. Therefore, we decided that the Plan does 
not have to pre-approve Freestyle Libre 3 Sensors
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve suture of recent small wound (D7910) and drugs or 
medicaments dispensed in the office for home use (D9630). 
 
You asked the Plan to pre-approve the dental services. You say that you are recommending these services due 
to the large amount of decay that go deep in the root. The Plan denied your request. The Plan says these 
services are not covered under the Plan's 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 pre-approve 
suture of recent small wound (D7910) and drugs or medicaments dispensed in the office for home use (D9630).