Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network orthopedic surgeon. 
 
You asked the Plan to pre-approve these services. You say that you were told you needed to seen an orthopedic 
surgeon. The Plan denied your request. The Plan says the services are available from network providers. 
 
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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral to an out-of-network orthopedic surgeon.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone marrow aspirate. 
 
You asked the Plan to pre-approve the bone marrow aspirate. You say that the enrollee has been doing home 
physical therapy programs since 2021. You say that the enrollee's last injection was about one month ago. You 
also say that the enrollee receives hydrocodone, Robaxin and gabapentin, in addition to using ice packs. The 
Plan denied your request. The Plan says this 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 bone marrow aspirate. Our reviewer says that the requested bone marrow aspirate is not considered medically reasonable and necessary in this case. 
Our physician reviewer found one marrow aspirate remains experimental for use as bone graft material in spine 
surgery. Therefore, the reviewer found that this is 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 bone marrow aspirate have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a bone marrow aspirate.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 heavy duty power operated vehicle, with a 
patient weight capacity of 301 to 450 pounds (K0801) 
 
You asked the Plan to pre-approve a group 1 heavy duty power operated vehicle. The Plan denied your request. 
The Plan says you do not meet the required weight range for the requested wheelchair under Centers for 
Medicare & Medicaid Services (CMS) guidelines.  
 
The Plan must follow Medicare rules. Medicare rules say that a PWC is covered if the beneficiarys weight is 
less than or equal to the weight capacity of the power wheelchair that is provided and greater than or equal to 
95% of the weight capacity of the next lower weight class PWC. Medicare rules also say if the base PWC is not 
covered, then related accessories will be denied. 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a group 1 heavy duty power operated vehicle have not been met. Specifically, the provided records 
show that your most recent documented weight is below the required weight limit of 301 to 450 pounds for a 
group 1 heavy duty power operated vehicle (K0801). Therefore, we decided that the Plan does not have to pre-
approve a group 1 heavy duty power operated vehicle, with a patient weight capacity of 301 to 450 pounds 
(K0801)
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 3, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
We looked at the file and Medicare rules. The file does not contain documentation of an established 
relationship between the enrollee and the ordering provider. Without a record showing that this provider is 
treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on April 3, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 20, 
2023. 
 You asked the Plan to pay for procedure code 70450. You say that 70450 should be covered because it is 
supported in the documentation and the enrollee had multiple exams on the same date of service. The Plan 
denied your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service April 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 87481, 87491, 87563, 87640, 87798, 87641, 87500, 
and 87653 for date of service December 15, 2022. 
 
You asked the Plan to pay for codes 87481, 87491, 87563, 87640, 87798, 87641, 87500, and 87653. You say 
that you disagree with the Plan's denial. The Plan denied your request. The Plan says the services billed are not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 87481, 87491, 87563, 87640, 87798, 87641, 87500, and 87653 is not supported in the 
medical record. Specifically, there is a more appropriate lab panel code that should be used when one or more 
codes are included in the same panel. The records do not support the codes, modifiers, and number of units 
billed. Based on this information, we decided that Medicare rules for coverage of codes 87481, 87491, 87563, 87640, 87798, 87641, 87500, and 87653 have not been met. Therefore, we decided that the Plan does not have 
to pay for codes 87481, 87491, 87563, 87640, 87798, 87641, 87500, and 87653 for date of service December 
15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown - porcelain fused to predominantly base 
metal (D6751) for teeth 6, 11 and 8, and a pontic - porcelain fused to predominantly base metal (D6241) for 
teeth 7, 9 and 10.  
 
You asked the Plan to pre-approve a retainer crown - porcelain fused to predominantly base metal (D6751) for 
teeth 6, 11 and 8, and a pontic - porcelain fused to predominantly base metal (D6241) for teeth 7, 9 and 10. 
You say that appealing with supporting records. The Plan denied your request. The Plan says to approve a 
bridge, the enrollee must be missing only one upper front tooth or only two lower front teeth, the two lower 
front teeth must be next to each other, and the enrollee also cannot be missing any of the back teeth. The Plan 
also says that their dentist looked at the x-rays you sent us and said the enrollee is missing other teeth.  
 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 a retainer 
crown - porcelain fused to predominantly base metal (D6751) for teeth 6, 11 and 8, and a pontic - porcelain 
fused to predominantly base metal (D6241) for teeth 7, 9 and 10 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 a retainer crown - porcelain fused to 
predominantly base metal (D6751) for teeth 6, 11 and 8, and a pontic - porcelain fused to predominantly base 
metal (D6241) for teeth 7, 9 and 10. Our reviewer says that the criteria for these services have not been met. 
Our physician reviewer found in this case, there are three maxillary anterior teeth being replaced and posterior 
missing teeth in the maxillary arch. 
 
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 a retainer crown - porcelain fused to predominantly base metal (D6751) for 
teeth 6, 11 and 8, and a pontic - porcelain fused to predominantly base metal (D6241) for teeth 7, 9 and 10 have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a retainer crown - porcelain 
fused to predominantly base metal (D6751) for teeth 6, 11 and 8, and a pontic - porcelain fused to 
predominantly base metal (D6241) for teeth 7, 9 and 10.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Epogen. 
 You asked the Plan to pre-approve Epogen. You say that Epogen is medically necessary. The Plan denied your 
request. The Plan says a trial of Procrit or Retacrit is required before Epogen can be considered. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Epogen. Our reviewer says that Epogen 
is not medically necessary. Our physician reviewer found the records do not show a trial of the plan preferred 
drugs or any reason they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Epogen have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Epogen.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee brace identified with codes L1852 and L2397 for 
date of service May 10, 2023. 
 
You asked the Plan to pay for the knee brace. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
 The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Review of the file shows that the medical records provided do not listed knee pain or arthritis as 
one of the enrollee's problems. There is no mention of the need for knee bracing. The medical records do not 
indicate knee pain or instability. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for the knee brace 
identified with codes L1852 and L2397 for date of service May 10, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient hospital admission associated with a planned 
procedure. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that it is better for you to receive hospital 
care after surgery than to return home without any support. The Plan denied your request. The Plan says there 
is no documentation provided to support the expectation that you will require a greater than 2 midnight stay 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the documentation does not support that an inpatient stay with anticipated greater 
than 2 midnights stay is medically 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for an inpatient hospital admission associated with a planned procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve the outpatient service. You say that the enrollee has been seeing this out-of-
network provider since 2022. The Plan denied your request. The Plan says this service can 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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided from October 28, 2022, 
to October 29, 2022. 
 
You asked the Plan to pay for outpatient services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says there are one or more I/OCE edit errors on this 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare rules say that providers must report 
services correctly. Providers must report services with the appropriate CPT code. The rules say that when an 
inpatient-only procedure is reported on an outpatient claim, the line is denied according to edit 18. All other 
services provided on the same date of service are subject to edit 49, which denies these services as well. The 
rules also say that packaged services are denied for separate payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of outpatient services have not been met. Specifically, procedure code 35371, which was performed 
on October 28, 2022, has a status indicator of C. This code is listed on the inpatient only list but is not 
defined as a separate procedure; therefore, the edit applies. This means that code 35371 and all other codes 
billed for date of service October 28, 2022, are denied. The codes remaining for date of service October 29, 
2022, includes J2270 and J0690, which each have a status indicator of N, and codes 36415, 80048 and 85027, 
which each have a status indicator of Q4. These are packaged services which are not separately payable. 
Therefore, we decided that the Plan does not have to pay for outpatient hospital services provided from October 
28, 2022, to October 29, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve extraction, erupted tooth requiring removal of bone and/or 
sectioning tooth, for tooth 2,20,21,22,23,28,29, 30 and 31 (D7210). 
 
You asked the Plan to pre-approve the extractions. You say that this is medically necessary. The Plan denied 
your request. The Plan says that this is not medically necessary. 
 
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 an extraction 
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 an extraction. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found a review of the documentation indicates 
that many of the indicated teeth to be extracted have severe coronal breakdown. The criteria for coverage of 
surgical extraction (D7210) have 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 an extraction have been met. Therefore, we decided that the Plan has to pre-
approve extraction, erupted tooth requiring removal of bone and/or sectioning tooth, for tooth 
2,20,21,22,23,28,29, 30 and 31 (D7210).  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve Prolia. You say that this drug is medically necessary. The Plan denied your 
request. The Plan says a trial of an injectable bisphosphonate is required before Prolia can be considered. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that Prolia is 
not medically necessary. Our physician reviewer found the records show no trial of the plan preferred drugs or 
any reason they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy provided on March 4, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the psychotherapy. You say that you are appealing the denial with supporting 
documentation. The Plan denied your request. The Plan says the service was not authorized. 
 
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 the psychotherapy provided on March 4, 2023, by 
an OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A0428 billed for date of service May 9, 
2023.   
You asked the Plan to pay for procedure code A0428. You say that you disagree with the denial. 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 A0428 is 2. The MAI value for this code is 3. You billed 4 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 A0428 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code A0428 billed for date of service May 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit to be provided by an OON provider.  
 
You asked the Plan to pre-approve the office visit. You say that your provider has a working relationship with 
this provider. The Plan denied your request. The Plan says there are network providers that can provide these 
services. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the office visit to be provided by an OON provider.