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

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the records provided support the 
services. The Plan denied your request. The Plan says the records do not show that the services the enrollee 
requires can only be given in a hospital setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not already available at 
the current facility. There are no services at the LTACH that the patient requires that are not already available 
and covered at the current facility. 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the guided tissue regeneration (D4266) and the 
extraction (D7250) for tooth #9 and to pay for the bone replacement graft (D7953) for tooth #9 provided on 
March 23, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you went to an in-network provider and 
the procedures were medically necessary. The Plan denied your request. The Plan says the proper cost share 
was applied. Also, the bone replacement graft is not covered by the Plan. 
 
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 total amount allowed for the guided tissue regeneration (D4266) was $517 and the total the Plan paid was 
$258.50 ($517 allowed x 50% payment). The total amount allowed for the extraction (D7250) was $245 and 
the total the Plan paid was $122.50 ($245 allowed x 50% payment). 
 
You have been asked to pay 50% of the cost for the guided tissue regeneration (D4266) and the extraction 
(D7250). This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The 
bone replacement graft is not covered under the Plans dental benefit. Therefore, we decided that the Plan does 
not have to pay more for the guided tissue regeneration (D4266) and the extraction (D7250) for tooth #9 and to 
pay for the bone replacement graft (D7953) for tooth #9 provided on March 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the liquid nutrition, Ensure light (enteral formula). 
 
You asked the Plan to pre-approve the Ensure light. You say that that the enrollee presents with Type 2 
Diabetes and requires the liquid nutrition. The Plan denied your request. The Plan says the Ensure light is not medically necessary. The Plan says you do not have a problem that does not allow you to get enough nutrition 
by mouth and you do not need a feeding tube to maintain a healthy weight and strength. 
 
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 Ensure light. Our reviewer says that 
the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has weakness and decreased appetite. The record shows the enrollee was described as well-
nourished on examination. The enrollee can eat by mouth. There was insufficient evidence from the notes of 
the enrollee having full or partial non-function or disease of the structures that normally permit food to reach 
the small bowel or of having a disease that impairs digestion and/or absorption of an oral diet, directly or 
indirectly, by the small bowel to meet criteria for this product. Therefore, the Ensure light will be considered 
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 the Ensure light have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the liquid nutrition, Ensure light (enteral formula).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional unit of procedure code 99285 billed for date of 
service March 22, 2023.  
 
You asked the Plan to pay for the additional unit of procedure code 99285. You say that the enrollee had 
multiple exams on this date of service. You also say that you would like this claim to be reprocessed. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 99285 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 99285 have not been met. Therefore, we decided that the 
Plan does not have to pay for the additional unit of procedure code 99285 billed for date of service March 22, 
2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the alcohol and/or substance (other than tobacco) misuse structured 
assessment (G0396) provided on June 9, 2022. 
 
You asked the Plan to pay for the outpatient service. You say that you do not know what you are being billed 
for. You also say that you have never been to this facility. The Plan denied your request. The Plan says that 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). 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient service have not been met. Review of the record in this case shows that you called a 
chemical dependency clinic, inquiring about resources for yourself for a family members substance abuse 
issue. The note indicates that you were given resources for family therapy. The note is insufficient to document 
that you were informed that you were speaking to a counselor, and we find that you would have no reasonable 
belief that the phone call would be considered a medical service. We find that your contract with the Plan does 
not clearly state how much you would expect to pay for speaking on the phone asking for family therapy 
resources. As such, we find that the application of a specialist visit copayment for this service is not appropriate 
based on your contract. Therefore, we decided that the Plan has to pay for the alcohol and/or substance (other 
than tobacco) misuse structured assessment (G0396) provided on June 9, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continued acute inpatient rehabilitation facility 
(IRF) services. 
 
You asked the Plan to pre-approve the continued IRF care starting August 17, 2023. You say that it is 
medically necessary for continued IRF care. The Plan denied your request. The Plan says the enrollee did not 
meet criteria for continued IRF care. 
 
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 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. 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 as 
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 the continued acute inpatient rehabilitation facility (IRF) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fungal polymerase chain reaction (PCR) panel (87798, 
87481) provided on May 12, 2022. 
 
You asked the Plan to pay for the fungal PCR panel. You say that this test was medically necessary and 
appropriate. The Plan denied your request. The Plan says this testing was not medically necessary as the 
requested testing exceeded the enrollee's medical needs. 
 
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 fungal PCR panel. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is insufficient evidence that molecular testing is necessary in the initial 
management of suspected onychomycosis. Documentation does not satisfy criteria outlined. 
 
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 fungal PCR panel have not been met. Therefore, we decided that the Plan 
does not have to pay for the fungal polymerase chain reaction (PCR) panel (87798, 87481) provided on May 
12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is weak and deconditioned 
and will need extensive rehabilitation to increase strength, independence with movement, and mobility. You 
also say the enrollee is unable to discharge to a skilled nursing facility or acute inpatient rehabilitation facility 
given their current needs. The Plan denied your request. The Plan says admission to an LTACH is not 
medically necessary.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that all medically necessary care is being provided in the current acute care setting.  There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (procedure code G0483) rendered on 
February 2, 2023. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says ordering a multi-class panel of definitive (confirmation) urine drug tests that are not 
used in clinical management exceeds the needs of the enrollee.  
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provider record notes no specific concern for drug abuse/misuse. There is no evidence that a 
urine drug screen (UDS) was performed, reviewed or inconsistent with prescriptions prior to ordering the 
testng. The testing was not tailored to the enrollees addictions and/or medications. Therefore, the 
documentation does not support that the provided, broad-sweeping, confirmatory urine drug testing was 
medically necessary or reasonable. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing services (procedure code G0483) rendered on February 2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PureWick system billed for dates of service January 20, 
2023, to February 19, 2023. 
 
You asked the Plan to pay for the billed services. You say that the machine prevents recurring urinary tract 
infections. The Plan denied your request. The Plan says the provider is not eligible to participate in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the PureWick system billed for dates of 
service January 20, 2023, to February 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365, 96366, and 96521 rendered on April 
27, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed, as the codes were not appropriate for the services 
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. 
 
In this case, the CPT Code Manual definition of the denied codes is:  
CPT 96365: 
 
Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour  
CPT 96366: 
 
Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour 
(List separately in addition to code for primary procedure) 
 
CPT 96521: 
 
Refilling and maintenance of portable pump. 
 
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 services at issue in 
this case were not supported by the medical records. Our reviewer found that the codes in question are not 
supported by the medical record. The record states that a continuous insulin infusion was performed with 
guidance by glucose measurements. According to CPT rules, there is a more specific code to report this 
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 procedure codes 96365, 96366, and 96521 rendered on April 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an at-home Covid-19 test (E1399). 
 
You asked the Plan to pre-approve an at-home Covid-19 test. You say that the item should be covered. The 
Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and an at-home 
Covid-19 test is an OTC item. Therefore, we decided that the Plan does not have to pre-approve an at-home 
Covid-19 test (E1399).
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 for the enrollee 
to learn how to walk again and get better. The Plan denied your request. The Plan says the enrollee does not 
meet the criteria for admission to an IRF. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and garment 
(E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and garment. You say that the items should 
be covered. The Plan denied your request. The Plan says there is no indication that you completed the Medicare 
criteria of at least four weeks of daily, multi-hour home usage of a basic lymphedema pump. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and garment (E0667).