Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88374 billed for date of service May 19, 
2022.   
You asked the Plan to pay for procedure code 88374. You say that you disagree with the Plan's 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 88374 is 5. The MAI value for this code is 3. You billed 6 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 88374 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88374 billed for date of service May 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mental health visit provided on May 30, 2023, by an OON 
provider.  
 
You asked the Plan to pay for a mental health visit. You say that you are requesting reconsideration of the 
denied claim. 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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 a mental health visit provided on May 30, 2023, 
by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abutment supported retainer for porcelain fused to metal 
FPD (high noble metal) (D6069) provided on May 9, 2023. 
 
You asked the Plan to pay for the dental service. You say that a crown should be a crown, despite its supporting 
structure. You also say that since the tooth extraction was medically necessary, it would also seem that portion 
of the procedure should be covered, as would any tooth extraction. The Plan denied your request. The Plan says 
service D6069 is not included in the list of covered services 
 
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 pay for the 
abutment supported retainer for porcelain fused to metal FPD (high noble metal) (D6069) provided on May 9, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0100). 
 
 
 You asked the Plan to pre-approve the additional trips. You say that you are seeking additional trips outside of 
32 rides because you have used your rides up and have many more appointments coming up. You also say that 
you have an average of two appointments a week.  The Plan denied your request. The Plan says the records 
show you have reached the benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 32 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve the 
additional routine transportation trips for your upcoming appointments. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0100).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee brace (L1851) and suspension sleeve (L2397), 
provided on June 2, 2023. 
 
You asked the Plan to pay for knee brace and suspension sleeve. You say that the items are medically 
necessary. The Plan denied your request. The Plan says the records provided do not show a recent injury or 
surgery to the enrollee's knee or any documentation that shows knee instability.  
 
The Plan follows Medicare rules. Medicare rules say that a knee orthosis, with an adjustable flexion and 
extension joint that provides both medial-lateral and rotation control (L1843, L1845, L1851, L1852), are 
covered if the beneficiary has had recent injury to or a surgical procedure on the knee(s). Knee orthoses L1832, 
L1833, L1843, L1845, L1851 and L1852 are also covered for a beneficiary who is ambulatory and has knee 
instability. 
 
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 knee brace and suspension sleeve. Our 
reviewer says that the items are not medically necessary. Our physician reviewer found the record lists 
osteoarthritis of both knees and history of knee surgery but did not indicate the date of knee surgery. There is 
no documentation of knee instability. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of knee brace and suspension sleeve have not been met. Therefore, we decided that 
the Plan does not have to pay for the knee brace (L1851) and suspension sleeve (L2397), provided on June 2, 
2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergency routine transportation trips (A0100) provided 
on provided on January 16, 2023, to May 31, 2023.  
 
You asked the Plan to pay for non-emergency routine transportation. You say that you are entitled to 
reimbursement of 40 cents per mile to transport yourself to medical appointments in your own personal vehicle. 
The Plan denied your request. The Plan says the service was not provided by the Plan's contracted vendor. 
 
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. 
 
You are not a contracted vendor with the Plan. The Plan had network providers available who could have 
provided the services at issue in this appeal. 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 non-emergency routine transportation trips (A0100) provided on provided on 
January 16, 2023, to May 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that the facet joint injections are medically 
necessary to treat the enrollee's current medical condition. The Plan denied your request. The Plan says the 
enrollee does not meet the criteria for the requested injection. 
 
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 facet joint injections. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the LCD criteria for a successful block is 80% pain relief. This requirement was not 
achieved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97116 and 97530 provided on May 25, 
2023. 
 
You asked the Plan to pay for procedure codes 97116 and 97530. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the code at issue is 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 97116 and 97530 are not supported in the medical record. Specifically, the code 
definition is time-based, and the records submitted for review do not document the total time spent providing 
the services described by this code. Based on this information, we decided that Medicare rules for coverage of 
procedure codes 97116 and 97530 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure codes 97116 and 97530 provided on May 25, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on May 18, 2023, to June 
07, 2023. 
 
You asked the Plan to pay for physical therapy services. You say that you are requesting reconsideration of the 
denied claims. 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 physical therapy 
services provided on May 18, 2023, to June 07, 2023.
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 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. There is not a 
reasonable expectation that the enrollee 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like to request reconsideration of the 
denied IRF services and that the services requested are medically necessary. The Plan denied your request. The 
Plan says the inpatient rehabilitation facility (IRF) services you are requesting do not meet the requirements for 
approval. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the Plan erred in its denial of IRF admission. Per Medicare Benefit Policy Manual, the medical record 
overall significantly complies with the various documentation requirements for IRF admission (e.g., as best 
summarized by the providers appeal letter from October 19, 2023).  This enrollees condition is in fact 
complex and fragile, and there is every reason to expect that they will participate in and benefit from IRF level 
services to include at minimum PT, OT, physician oversight of polypharmacy and cardio/renal function. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that a delay in decision for an acute rehabilitation stay 
will jeopardize the enrollee's chance for a full recovery. The enrollee will clearly benefit from acute rehab to 
optimize his level of functioning prior to returning home. They require interdisciplinary therapy care 
(Occupational Therapy, Physical Therapy). They have a serious, life threatening constellation of acute medical 
problems that have left them at a functional status below their baseline. The Plan denied your request. The Plan 
says the inpatient rehabilitation facility (IRF) services you are requesting do not meet the requirements for 
approval. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the Plan erred in its denial of IRF admission. Per Medicare Benefit Policy Manual, the medical record 
overall complies with the various documentation requirements for IRF admission (e.g., as best summarized by 
the PT note from October 17, 2023, and the OT note from October 18, 2023).  This enrollees condition is in 
fact complex and fragile, and there is adequate reason to expect that they will participate in and benefit from 
IRF level services. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (15004, 15275, 82947, A6209, J0171, 
J0690, J2405, J2704, J3010, Q4100) provided on May 26, 2023. 
 
You asked the Plan to pay for the surgical 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 15004, 15275, 82947, A6209, J0171, J0690, J2405, J2704, J3010, & Q4100 are not 
supported in the medical record. Specifically, code 15275 is a high-cost skin substitute code, however the claim 
did not include a product code. This coding error requires the claim to be returned to the provider per 
Outpatient Code Editor (OCE) edit 87. Based on this information, we decided that Medicare rules for coverage 
of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (15004, 15275, 82947, A6209, J0171, J0690, J2405, J2704, J3010, Q4100) provided on May 
26, 2023.
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 this is medically necessary. The Plan 
denied your request. The Plan says this 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 the enrollee is receiving appropriate care in current acute care setting as provided by 
Health Plan. Documentation does not support that LTACH services are medically appropriate at this time. 
 
 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kidney transplant evaluation to be provided by an out-
of-network provider. 
 
You asked the Plan to pre-approve the transplant evaluation. You say that you are trying to remain on the 
transplant list. The Plan denied your request. The Plan says this service can be provided in-network. 
 The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 the out-of-network transplant 
evaluation have been met. No medical records were submitted to review to determine if your transplant care 
needs can be met with an in-network provider. Therefore, we decided that the Plan does not have to pre-
approve a kidney transplant evaluation to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the crown - porcelain fused to predominantly base metal 
(D2751) Tooth #6 and 8. 
 
You asked the Plan to pre-approve the dental services. You say that you do not agree with the denial of the 
requested crowns. 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 you previously received a crown - porcelain fused to predominantly base metal (D2751) Tooth #6 on 
date of service March 31, 2021, and a crown - porcelain fused to predominantly base metal (D2751) Tooth #8 
on date of service February 8, 2021. Therefore, these benefits have been exhausted. Therefore, we decided that 
the Plan does not have to pre-approve the crown - porcelain fused to predominantly base metal (D2751) Tooth 
#6 and 8.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on February 10, 2022 to 
March 9, 2022. 
 You asked the Plan to pay for the home health services. You say that this service was medically necessary. 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 February 10, 2022. The NOA was not received by the Plan until May 13, 
2023. 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 
on February 10, 2022 to March 9, 2022.