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

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that in consideration of the enrollee's prior medical 
history, active comorbidities, and risk for medical instability while increasing activity, the IRF setting is the 
most appropriate to reach the desired outcomes. The Plan denied your request. The Plan says  the enrollee does 
not meet all the required 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 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. 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 
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 an IRF admission and services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Granix. 
 You asked the Plan to pre-approve Granix. You say that the requested drug is medically necessary.  The Plan 
denied your request. The Plan says that you must first try or be unable to use the Plan's preferred medication 
which is Zarxio.  
 
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 Granix. Our reviewer says that the 
elements of the coverage criteria are not satisfied. Our physician reviewer found that the provided records do 
not indicate that you have tried and failed the Plan's preferred step one alternative. The records do not indicate 
that you have a contraindication to or would have an adverse effect from the Plan's preferred step one 
alternative.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Granix have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Granix.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the items denied correctly as they do not meet the clinical 
requirements to be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that a non-adjunctive continuous glucose monitor 
(CGM) must be billed with code E2103. The rules also say that only devices reviewed by the PDAC and 
assigned code E2103 may be billed using this code.   
We looked at the file and Medicare rules. The request at issue is for the Freestyle Libre 3 non-adjunctive CGM. 
However, this device has not been reviewed by the PDAC and has not been assigned code E2103. As such, this 
non-adjunctive CGM device is not eligible for coverage at this time. Therefore, we decided that the Plan does 
not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on July 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your annual maximum limit 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 your benefit for the requested item or service was exhausted. Therefore, we decided that the Plan does 
not have to pay for dental services provided on July 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transforaminal placement (64581). 
 
You asked the Plan to pre-approve transforaminal placement. 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 effective January 1, 2002, sacral nerve stimulation is 
covered for the treatment of urinary urge incontinence, urgency-frequency syndrome, and urinary retention. 
 
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 transforaminal placement. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the enrollee does not meet the 
coverage criteria detailed in the NCD for open implantation of neurostimulator electrode array; sacral nerve 
(transforaminal placement). The NCD requires a successful test stimulation in order to support subsequent 
implantation. The records do not show that the enrollee has had a successful test stimulation trial. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transforaminal placement have not been met. Therefore, we decided that the 
Plan does not have to pre-approve transforaminal placement (64581).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99215 provided on February 15, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for procedure code 99215 provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide OON care. 
 
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. We found no exception that would 
require the Plan to pay for procedure code 99215 provided by an OON provider. Therefore, we decided that the 
Plan does not have to pay for procedure code 99215 provided on February 15, 2023, by an out-of-network 
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3020). 
 
You asked the Plan to pre-approve foot orthotics. You say that the items should be covered as the enrollee 
disagrees with the denial. The Plan denied your request. The Plan says this item is not a covered benefit as the 
item is not an integral part of a brace. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
 
  Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot 
orthotics (L3020).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility services provided on April 29, 2021. 
 
You asked the Plan to pay for the SNF services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim was not received within the filing time frame. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the SNF services was not filed until March 2, 2023. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for skilled nursing facility services provided on April 29, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services and ground mileage provided on January 
6, 2022. 
 
You asked the Plan to pay for the ambulance services and ground mileage. You say that the claim was on hold 
for incomplete medical records. The Plan denied your request. The Plan says the claim was untimely, and the 
submission did not meet the exception criteria guidelines. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the ambulance services and ground mileage was not filed until January 13, 
2023. This means that more than one calendar year from the date of service had passed before a claim was 
filed. Therefore, we decided that the Plan does not have to pay for ambulance services and ground mileage 
provided on January 6, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for custodial care provided October 9, 2022, to October 15, 
2022. 
 
You asked the Plan to pay for custodial care. You say that the enrollee fractured her elbow and needed help 
with daily care. The Plan denied your request. The Plan says custodial care is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of custodial care have not been met. Specifically, we find that the services at issue in this case are 
considered custodial in nature. Therefore, we decided that the Plan does not have to pay for custodial care 
provided October 9, 2022, to October 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive evaluation (D0150) and intraoral 
radiographic image-including bitewing (D0210) provided on March 8, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. 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 your benefit for the requested item or service was exhausted on date of service June 9, 2022. Therefore, 
we decided that the Plan does not have to pay for comprehensive evaluation (D0150) and intraoral radiographic image-including bitewing (D0210) provided on March 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral- periapical each additional radiographic image 
(D0230) provided on February 20, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. 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 your benefit for the requested item or service was exhausted on date of service February 20, 2023. 
Therefore, we decided that the Plan does not have to pay for intraoral- periapical each additional radiographic 
image (D0230) provided on February 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88305 billed for date of service March 1, 
2023.  
You asked the Plan to pay for procedure code(s) 88305. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this code is included in the skilled nursing facility payment and is not 
separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the SNF for its Part A inpatients and are not separately payable. 
 
The records indicate that this service was provided to the enrollee while a SNF inpatient. Per the Physician Fee 
Schedule, CPT code 88305 has a Professional/Technical indicator of 1. This means that CPT code 88305 has 
both a professional and technical component. In this case, CPT code 88305 has not been billed with an 
appropriate modifier to indicate the professional component. Based on this information, we decided that 
Medicare rules for coverage of procedure code 88305 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code(s) 88305 billed for date of service March 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87641, 87481 and 87653 billed for 
date of service December 27, 2022. 
 
You asked the Plan to pay for procedure codes 87150, 87641, 87481 and 87653. You say that these services 
were reported appropriately and are supported in the medical record. The Plan denied your request. The Plan 
says these services are not supported for separate billing/reporting. 
 
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 codes 87150, 87641, 87481 and 87653 are column II codes to column I 
codes 87500 and 87801. Code 87481 has not been billed with an appropriate modifier to bypass the edit. Based 
on the claim submitted, Medicare billing criteria have not been met for code 87481. However, codes 87150, 
87641, and 87653 were each billed with a modifier.  
 
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 procedure codes 87150, 87641, and 87653. Our reviewer 
says that these services are not supported for separate billing/reporting. Our reviewer found the laboratory 
report does not include documentation to support these procedures are unusual non-overlapping services from 
codes 87500 and 87801, which have already been approved. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87150, 87641, 87481 and 87653 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 87150, 87641, 87481 and 87653 billed for 
date of service December 27, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve prosthesis additions identified with codes L5828, L5845, L5850, 
L5925, L5981, and L5986. 
 
You asked the Plan to pre-approve prosthesis additions identified with codes L5828, L5845, L5850, L5925, 
L5981, and L5986. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan 
says that the requested items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that prosthesis additions are covered for certain 
indications. 
 
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 prosthesis additions identified with 
codes L5828, L5845, L5850, L5925, L5981, and L5986. Our reviewer says that the documentation supports 
that the requested items are medically reasonable and necessary. Our physician reviewer found the enrollee has 
a right transfemoral amputation since September 2022 in the setting of peripheral vascular disease. The 
documentation shows that the enrollee is a K3 ambulator. Both the certified prosthetist/orthotist and 
prescribers notes submitted very thoroughly and explicitly document the enrollee's K3 potential, and, contrary 
to the Plans assertions, credibly assert that the enrollee's overall medical condition is stable and well managed 
enough to permit the enrollee to fulfill the K3 potential. Therefore, the enrollee meets criteria for the requested 
items. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prosthesis additions identified with codes L5828, L5845, L5850, L5925, L5981, 
L5986 have been met. Therefore, we decided that the Plan has to pre-approve prosthesis additions identified 
with codes L5828, L5845, L5850, L5925, L5981, and L5986.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural injection.  
 You asked the Plan to pre-approve the injection. You say that the enrollee has severe chronic pain causing them 
to have limited functionality and mobility. The Plan denied your request. The Plan says an epidural injection 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 injection. Our reviewer says that the 
enrollee does not meet the coverage criteria. Our physician reviewer found the proposed level of injection and 
approach are not detailed in any notes. Therefore, the request for the epidural injection 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a limited oral evaluation - problem focused (D0140), 
intraoral - periapical first radiographic image (D0220), and panoramic radiographic image (D0330) provided 
on February 27, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you should be covered for $120 for the 
services as your flex debit card was active. The Plan denied your request. The Plan says you are responsible for 
any charged amount above the Plans cost-sharing amount when your services are received from an out-of-
network provider.  
 
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. 
 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for a limited oral evaluation - problem focused 
(D0140), intraoral - periapical first radiographic image (D0220), and panoramic radiographic image (D0330) 
provided on February 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions, erupted tooth or exposed root (D7140 x5) 
provided on February 7, 2023. 
 
You asked the Plan to pay for the dental services. You say that these services were necessary to prevent 
additional health problems. The Plan denied your request. The Plan says your benefit for the extractions, 
erupted tooth or exposed root (D7140 x5) $1,500 dollar limit was met. 

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the extractions, erupted tooth or exposed root (D7140 x5) was exhausted on date of 
service February 7, 2023. Therefore, we decided that the Plan does not have to pay for the  extraction, erupted 
tooth or exposed root (elevation and/or forceps removal) (D7140 x5) provided on February 7, 2023.