Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740), core buildup (D2950) and 
gingivectomy to allow access for restorative procedure (D4212). 
 
You asked the Plan to pre-approve the dental services. You say that these procedures are medically necessary. 
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 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 a 
crown (D2740), core buildup (D2950) and gingivectomy to allow access for restorative procedure (D4212).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 6, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that this is supported in the records. The Plan denied 
your request. The Plan says this 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 an office visit provided on March 6, 2023, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient care provided from March 24, 2022, to  
April 20, 2022. 
 
You asked the Plan to pay for inpatient care. The Plan denied your request. The Plan says a corrected claim 
was not submitted to the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of inpatient care have been met. A 
corrected claim was not provided. Therefore, we decided that the Plan does not have to pay for inpatient care 
provided from March 24, 2022, to April 20, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a capsule endoscopy (91110). 
 
You asked the Plan to pre-approve a capsule endoscopy. You say that it is not recommended to repeat 
coloscopy at this time and instead to proceed with video capsule endoscopy to evaluate if the enrollee has any 
small bowel pathology. The Plan denied your request. The Plan says the records do not show that the enroll had 
a colonoscopy within the past 12 months. 
 
The Plan must follow Medicare rules. Medicare rules say that a wireless capsule endoscopy is covered for 
enrollees who have had upper and lower GI endoscopies within the past 12 months.  
 
We looked at the file and Medicare rules. The records show the enrollee has not had a lower endoscopy in the 
past 12 months. Based on this information, we decided that Medicare rules for coverage of a capsule endoscopy 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a capsule endoscopy 
(91110).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99285 billed for date of service August 8, 2022. 
 
You asked the Plan to pay for code 99285. You say that these services were reasonable and necessary. Code 
99285 accurately reflects the treatment and documentation provided. The Plan denied your request. The Plan 
says code 99285 is not supported by the medical records. The records do not support medical decision making 
of high complexity. 
 
The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect 
the services provided.   
 
In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the 
evaluation and management of a patient which requires three components (taking into account the urgency of 
the clinical condition or the patient's mental status): 
 1. a comprehensive history; 
2. a comprehensive examination; and 
3. medical decision making of high complexity. 
 
In addition, CPT code 99285 usually includes a presenting medical problem of high severity and immediate 
significant threat to life or physiologic function.  
 
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 code 99285 Our reviewer says that code 
99285 is not supported by the medical record. Our reviewer found the member is a 75-year-old female with a 
medical history including gastroesophageal reflux disease, hypertension and dementia who was evaluated and 
treated in the emergency department for nausea with vomiting. She was hemodynamically stable at the time of 
presentation. She was treated with IV fluids, steroids, Zofran and anti-infective medications. The member was 
diagnosed with an acute infection with COVID-19 and was discharged home the same day. The documentation 
available for review does not support that the presenting problems were of high severity or that the medical 
decision was of high complexity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99285 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99285 billed for date of service August 8, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 You asked the Plan to pre-approve Evenity. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy requirements have not been met. 
 
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 Evenity. Our reviewer says that the 
requirements for coverage of Evenity have not been met. Our physician reviewer found the Plan requires a trial 
of an injectable bisphosphonate (Pamidronate or Zoledronic Acid) before they will approve Evenity. In this 
case, the enrollee has not tried and failed the required drugs. There is no documentation provided indicating 
that the required drugs would likely be less effective or have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on January 31, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim is not 
payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that an Excludes1 note indicates that the code 
excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 indicates 
that the two conditions cannot occur together.  
 
We looked at the file and Medicare rules. In this case, the claim was billed with diagnosis codes D64.9 and 
D46.C. Diagnosis codes D64.9 has an Excludes1 note and cannot be billed with diagnosis code D46.C. 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 the services provided on January 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on April 12, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the member must receive care from a network provider 
or it will not be covered except for urgent/emergency care, get approval to see an out-of-network doctor, or 
kidney dialysis services from a Medicare-certified dialysis facility outside the Plans service area. In this case, 
prior authorization was not obtained. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for subsequent nursing facility care provided on April 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 3, 2022. 
 
You asked the Plan to pay for the lab services. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on November 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a vagus nerve stimulator (VNS).  
 
You asked the Plan to pre-approve the VNS placement. You say that traditional rehabilitation therapy after his 
stroke failed, and the enrollee has permanent disability with no other treatment options available to aid him in 
recovery. The Plan denied your request. The Plan says the requested therapy is not a permissible treatment for 
the noted indication.  
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 VNS placement. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee suffered an ischemic stroke in 2015. The enrollee reportedly plateaued in 
progress on in February 2023. There is insufficient evidence supporting the long-term benefit of open 
implantation of a cranial nerve neurostimulator electrode array and pulse generator for the management of 
hemiparesis following stroke. Additional study is needed to address gaps in the current evidence. 
 
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 VNS placement have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of a vagus nerve stimulator (VNS).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for four additional units of procedure code 88377 rendered on 
February 17, 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 there was no specific rationale for why the additional units would need to be performed. 
 
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 88377 is "Morphometric analysis, in situ hybridization 
(quantitative or semi-quantitative), manual, per specimen; each multiplex probe stain procedure." 
 
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 although the records do support 
that four additional units were performed, the records do not support that these additional services were 
medically reasonable or necessary. 
 
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 four additional units of procedure code 88377 rendered on February 17, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 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 that the complexity of the enrollees 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. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services provided on 
March 23, 2023. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that you were not 
evaluated by the provider and you should not have to pay. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $95 
copayment for emergency care. 
 
You have been asked to pay a $95 copayment for the emergency room services. This item/service falls within 
the emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. However, since the allowed amount is less than the standard copayment, you only owe $78.82. 
Therefore, we decided that the Plan does not have to waive the copayment for the emergency room services 
provided on March 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive metabolic panel provided on January 25, 
2023. 
 
You asked the Plan to pay for comprehensive metabolic panel. You say that the services should be covered. 
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 comprehensive 
metabolic panel provided on January 25, 2023.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance services (A0427) provided on December 13, 2022. 
 
You asked the Plan to pay for ambulance services. You say that these were ET3 ambulance services, and the 
"W" modifier is appropriate in this case. The Plan denied your request. The Plan says that modifier "W" is an 
invalid destination modifier on ambulance claims. 
 
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 code A0427-RW is supported in the medical record. Specifically, modifier W is an 
appropriate destination modifier for use with ET3 ambulance claims. Based on this information, we decided 
that Medicare rules for coverage of the ambulance services have been met. Therefore, we decided that the Plan 
has to pay for ambulance services (A0427) provided on December 13, 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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the Group 3 power wheelchair (PWC) with multiple power options, 
power tilt and recline, and expandable controller provided on October 22, 2022. 
 
You asked the Plan to pay for the Group 3 PWC and accessories. You say that this claim partially paid. You 
say that a valid authorization has been provided. You also say that this should be reprocessed and paid. The 
Plan denied your request. The Plan says that payment was made according to the Medicare allowable rate. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The file does not support the Plan's denial that payment was made for these 
services. Therefore, we decided that the Plan has to pay for the Group 3 power wheelchair (PWC) with 
multiple power options, power tilt and recline, and expandable controller provided on October 22, 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on February 20, 2023. 
 
You asked the Plan to pay for the psychotherapy. You say that you have no control over who is in the nursing 
home and you are required to see all patients. The Plan denied your request. The Plan says non-emergent, non-
urgent services with out-of-network providers require prior authorization. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for psychotherapy provided on February 20, 2023.