Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 23, 2022 to 
April 21, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the home health services were 
medically necessary. 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 March 23, 2022 to April 
21, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve inpatient psychiatric care from June 22, 2023, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that the services are 
medically necessary. The Plan denied your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve inpatient psychiatric hospital services. 
Our reviewer says that the services are medically necessary. Our physician reviewer found this enrollee did 
show some auditory hallucinations but no visual hallucinations. The enrollee was showing acute threats to 
safety. It did appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient 
level of care rather than a lower level of care beyond the dates in question as the enrollee did have 
dangerousness to others and was not compliant with treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospital services have been met. Therefore, we decided 
that the Plan has to pre-approve inpatient psychiatric care from June 22, 2023, forward.  
 
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 pre-approve a crown - porcelain/ceramic tooth #12 (D2740). 
 
You asked the Plan to pre-approve the crown. You say that tooth #12 had fractured on all surfaces and needs 
full crown coverage.  The Plan denied your request. The Plan says the documentation does not meet the criteria 
for the crown - porcelain/ceramic. 
 
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 crown 
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 crown. Our reviewer says that 
criteria for a crown has not been met. Our physician reviewer found the radiograph appearance of #12 is what 
appears to be that of a supernumerary tooth, with a small root and small crown size. The remaining structure 
appears to be heavily reduced or fractured. There is also a substantial loss of bone on the distal of the root in 
the order of more than 50%. Given the inability to properly prepare and retain a crown in the long term due to 
bone loss, a crown would not be necessary for a crown on this tooth. 
 
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 crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown - porcelain/ceramic tooth #12 (D2740).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99233 billed for date of service January 30, 2023. 
 
You asked the Plan to pay for code 99233. You say that medical records have been provided to support 
payment. The Plan denied your request. The Plan says code 99233 is not supported by the medical record. The 
medical records do not support a detailed interval history or medical decision making of high complexity. 
 
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 99233 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of the 3 key components: A detailed interval 
history; A detailed examination; Medical decision making of high 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 99233. Our reviewer says that code 99233 is not 
supported by the medical records. Our reviewer found the provided documentation does not sufficiently 
support a detailed history or medical decision-making of high complexity to justify use of this code for this 
encounter. The history stated "Patient seen examined. No significant changes in condition since last visit." and 
the vitals were stable. The patient was treated with dressing changes only."  
 
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 99233 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99233 billed for date of service January 30, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 30, 2022, to 
September 28, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. 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 August 30, 2022, to 
September 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a functional electrical stimulator, transcutaneous 
stimulation of nerve and/or muscle groups, any type, complete system, not otherwise specified (E0770). 
 
 
You asked the Plan to pre-approve a functional electrical stimulator. You say that you need a device to 
stimulate your muscles in your left leg. You have traumatic brain injury with left side paralysis and drop foot. 
The Plan denied your request. The Plan says the enrollee does not meet the Medicare medically necessary 
criteria. 
 
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 a functional electrical stimulator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is a small randomized controlled trial supporting use of a nerve 
stimulator for peroneal stimulation in setting of hemiplegia. Persons with diabetes were excluded from the trial. 
The trial also excluded individuals with more than 5 degrees of dorsiflexion with the knee extended. The 
request does not provide sufficient information about the enrollee's functional status and goal of using the 
device. The device's efficacy in setting of chronic glucose intolerance is not established. Per SSA 1862 (a)1 (A) 
as the device is not standard of care for the enrollee's condition. 
 
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 functional electrical stimulator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a functional electrical stimulator, transcutaneous stimulation of nerve 
and/or muscle groups, any type, complete system, not otherwise specified (E0770).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0429, A0425) provided on September 
26, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
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 codes A0429, & A0425 are not supported in the medical record. Specifically, the ambulance 
services were provided when the enrollee was an inpatient. The services are included in the hospital payment 
and are not separately payable. Based on this information, we decided that Medicare rules for coverage of the 
ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance 
services (A0429, A0425) provided on September 26, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda, Carboplatin, Pemetrexed, palonosetron, 
fosaprepitant, and dexamethasone.  
 
You asked the Plan to pre-approve Keytruda, Carboplatin, Pemetrexed, palonosetron, fosaprepitant, and 
dexamethasone. You say that the first time the enrollee took the medication was without chemotherapy, and 
now you would like to try it with the chemotherapy. The Plan denied your request. The Plan says the requested 
treatment is not considered medically necessary for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
 
 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 Keytruda, Carboplatin, Pemetrexed, 
palonosetron, fosaprepitant, and dexamethasone. Our reviewer says that the service is not medically necessary. 
Our physician reviewer found the enrollee has had previous progression on Keytruda. Therefore, the requested 
drugs cannot be approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda, Carboplatin, Pemetrexed, palonosetron, fosaprepitant, and 
dexamethasone have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda, 
Carboplatin, Pemetrexed, palonosetron, fosaprepitant, and dexamethasone.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve moderate sedation services (99152). 
 
You asked the Plan to pre-approve moderate sedation services. 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 use of Moderate or Deep Sedation, General 
Anesthesia, or Monitored Anesthesia Care (MAC) is usually unnecessary or rarely indicated for these 
procedures and therefore, is not considered medically reasonable and 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 moderate sedation services. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the provided 
documentation did not clearly describe the enrollee's quantified severe pain, or the indication for sedation during a procedure that typically does not include moderate sedation as oral mild sedation, or none usually 
suffices. She can tolerate oral medications. No explanation or justification was seed in the documentation for 
sedation. Therefore, this request for such will be considered not medically necessary at this time based on the 
provided documentation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of moderate sedation services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve moderate sedation services (99152).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2740 x 4) for tooth number's 7-10. 
 
You asked the Plan to pre-approve the dental services. You say that due to an accident your teeth are fractured, 
and crowns are required. The Plan denied your request. The Plan says 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. The Plan's rule says for crown's to be 
covered there has to be 50% or more loss of tooth structure. 
 
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 not medically reasonable and necessary. Our physician reviewer found that the 
documentation indicates that teeth number's 7-10 do not exhibit significant coronal breakdown due to caries or 
fracture to warrant crown restorations. The criteria for coverage for crown restorations have not been met.  
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 not been met. Therefore, we decided that the Plan does 
not have to pre-approve crowns (D2740 x 4) for tooth number's 7-10.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on December 03, 2022, to 
December 24, 2022. 
 
You asked the Plan to pay for a nursing facility visit. You say that you depend on the facility staff to verify 
eligibility and to obtain authorization. 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 a nursing facility visit 
provided on December 03, 2022, to December 24, 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 6, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the Plan's 
denial. 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 
6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve VIA Disc Intradiscal Therapy (0627T). 
 
You asked the Plan to pre-approve injections. You say that the injections are medically necessary for the 
enrollee. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not 
covered by Medicare due to insufficient evidence of efficacy. There are not enough studies on VIA Disc 
Intradiscal Therapy to show it is safe and effective. 
 
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 injections. 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 chronic low back pain. She has tried NSAIDs, physical therapy, and a home 
exercise program. Imaging shows multi-level degenerative disc disease and annula fissures. This is considered 
an experimental/ investigational therapy at this time. Therefore, the request is deemed not medically reasonable 
and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve VIA Disc Intradiscal Therapy (0627T).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87481 billed for date of service December 5, 
2022. 
 
You asked the Plan to pay for procedure code 87481. You say that the patient shouldn't be penalized because 
their doctor sent their sample to an out-of-network lab. The Plan denied your request. The Plan says payment 
for code 87481 is bundled into payment for code 87801. 
 
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 87481 
is a column II code to column I code 87801. 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 87481 billed for date of service December 5, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty at T6. 
 
You asked the Plan to pre-approve a kyphoplasty. You say that the requested kyphoplasty is medically 
necessary. The Plan denied your request. The Plan says the requested procedure is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that PVA is considered reasonable and necessary for 
osteoporotic conditions when the enrollee has an acute or subacute VCF, is symptomatic, and has been 
hospitalized for severe pain. The rules also say that the enrollee must not have any listed contraindications.  
 
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 kyphoplasty. Our reviewer says that 
the coverage criteria has not been met. Our physician reviewer found that there is no documented trial of 
bracing. More conservative measures are needed. 
 
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 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a kyphoplasty at T6.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the presumptive drug screening (80307) provided December 
1, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that it is appropriate to treat symptoms but 
medically necessary to send of specimens if in-house is not available., in order to get a true and accurate diagnosis. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and 
was correctly denied. 
 
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 January 9, 2023. 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 the laboratory service have not been met. 
Therefore, we decided that the Plan does not have to pay for the presumptive drug screening (80307) provided 
December 1, 2022.