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

 
We decided that the Plan does not have to pay for inpatient hospital services denied on the Plans Itemized Bill 
Determination with denial codes F, G and H, provided on May 10, 2022, to June 1, 2022. 
 You asked the Plan to pay for the inpatient hospital services. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the services 
billed. 
 
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. 
 
We asked our coding 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 inpatient hospital services denied. Our 
reviewer says that that the services were denied correctly. Our physician reviewer found that for date of service 
May 15, 2022, healthcare provider reported $2,308.00 for HC SUPPLY - STERILE, however after review of 
medical record this charge cannot be verified.  In this case, this procedure denied correctly. Charges for 
$15,728.80 denied correctly, as these services would be considered routine "room and board" charges, which 
would not be separately billed. Charges for $2,146.00 denied correctly, as vent management, initial day, and 
vent management subsequent day were billed on same date of service, May 13, 2022.  Per Medical record 
ventilation support was started on May 13, 2022.  Therefore, ventilation subsequent day resulted in duplicate 
billed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient hospital services denied have not been met. Therefore, we decided that 
the Plan does not have to pay for inpatient hospital services denied on the Plans Itemized Bill Determination 
with denial codes F, G and H, provided on May 10, 2022, to June 1, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from January 6, 2022, to 
January 21, 2022. 
 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 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 January 6, 2022. The NOA was not received by the Plan until March 10, 
2022. 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 the home health services 
rendered from January 6, 2022, to January 21, 2022.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Synvisc One.

You asked the Plan to pre-approve Synvisc One. You say that the requested drug is a necessity for your care. The Plan denied your request. The Plan says rules for coverage of Synvisc One have not been met.

The Plan must follow Medicare rules. Medicare rules say that repeat injections for shoulder arthritis are limited to a single repeat course.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc One have not been met. Specifically, the Plan has documented that you have already received an initial and a repeat course of Synvisc One injections for shoulder arthritis. No further repeat courses can be authorized. Therefore, we decided that the Plan does not have to pre-approve treatment with Synvisc One.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic images (D0220 and D0230) 
provided on April 22, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were told that you can use any dentist and 
you would like the Plan to cover the dental services. The Plan denied your request. The Plan says the denial of 
payment for these services is correct, because the intraoral radiographic images are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 
intraoral radiographic images (D0220 and D0230) provided on April 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown (D6752) for tooth #10. 
 
You asked the Plan to pre-approve the dental service. You say that the dentist is going to do a bridge for a 
replacement tooth. 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 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 the Plan pre-approved a pontic (D6245) for tooth #9 and a retainer crown (D6752) for tooth #8 on June 
2, 2023; therefore, your benefit for the requested item or service was exhausted on the date of approval of June 
2, 2023. Therefore, we decided that the Plan does not have to pre-approve a retainer crown (D6752) for tooth 
#10.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the item is medically necessary. The Plan 
denied your request. The Plan says that the item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
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 home ventilator. Our reviewer says 
that the item is medically necessary. Our physician reviewer found the patient has COPD with associated 
chronic respiratory failure and has been treated with Trilogy ventilator since 2018. To withdraw this successful 
treatment is substandard of care and not best practice. Hence, continued therapy with trilogy ventilator is 
indicated.  The ventilator will not be used as BIPAP or CPAP therapy. 
 
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 home ventilator have been met. Therefore, we decided that the Plan has to 
pre-approve the home ventilator (E0466).  
 
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 pre-approve  a bi-level positive airway pressure (BiPAP) device (E0470) and 
accessories. 
 
You asked the Plan to pre-approve a BiPAP device and accessories. You say that the item is medically 
necessary. The Plan denied your request. The Plan says that the records do not show clinical re-evaluation. 
 
The Plan follows Medicare rules. Medicare rules say that continued coverage of a PAP device (E0470 or 
E0601) beyond the first three months of therapy requires that, no sooner than the 31st day but no later than the 
91st day after initiating therapy, the treating practitioner must conduct a clinical re-evaluation and document 
that the beneficiary is benefiting from PAP therapy. For PAP devices with initial dates of service on or after 
November 1, 2008, documentation of clinical benefit is demonstrated by: 
1. In-person clinical re-evaluation by the treating practitioner with documentation that symptoms of obstructive 
sleep apnea are improved; and, 
2.Objective evidence of adherence to use of the PAP device, reviewed by the treating practitioner. 
 
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 BiPAP device and accessories. Our 
reviewer says that the item is medically necessary. Our physician reviewer found that BiPAP is the appropriate 
therapy and standard of care to treat the enrollee's disease process. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a BiPAP device and accessories have been met. Therefore, we decided that the 
Plan has to pre-approve  a bi-level positive airway pressure (BiPAP) device (E0470) and accessories.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 18, 2023, 
to March 19, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that the documentation required was 
submitted. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 The Plan follows Medicare rules. The rules say that an NOA must be submitted for the first period of care in 
2022, using the first date of the period as the admission date. Subsequent claims must report this new date as 
the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date on the NOA as required. Based on this information, we find that the Medicare rules for 
payment of the claim at issue have not been met. Therefore, we decided that the Plan does not have to pay for 
the home health services provided from February 18, 2023, to March 19, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of interlaminar/interspinous process 
stabilization/distraction device at L3-L4 and L4-L5. 
 
You asked the Plan to pre-approve the insertion of interlaminar/interspinous process stabilization/distraction 
device. You say that this procedure would benefit the enrollee. The Plan denied your request. The Plan says the 
enrollee is not currently enrolled in a Medicare approved clinical study for this device. 
 
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 insertion of 
interlaminar/interspinous process stabilization/distraction device. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found interspinous distraction devices are experimental, and more research is needed.  
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 insertion of interlaminar/interspinous process stabilization/distraction device 
have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of 
interlaminar/interspinous process stabilization/distraction device at L3-L4 and L4-L5.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-precision attachment (D6052) for tooth #23 and 
#26. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denied dental 
services. The Plan denied your request. The Plan says the denial of authorization for these services is correct, 
because the semi-precision attachment is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 
semi-precision attachment (D6052) for tooth #23 and #26.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for colonoscopy provided on April 25, 2023. 
 
You asked the Plan to waive the copayment for colonoscopy. You say that you say that there is no copayment. 
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 $10 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $10 copayment for colonoscopy. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies 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. Therefore, we decided that the Plan does not have to waive the 
copayment for colonoscopy provided on April 25, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have copayment for skilled nursing facility (SNF) care provided on January 
5, 2023, to January 28, 2023.  
 
You asked the Plan to waive the copayment for skilled nursing facility (SNF) care provided on January 5, 2023, to January 21, 2023. You say that the enrollee was only in an SNF for 16 days. 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 $0 
copayment each day for Medicare-covered days 1 to 20. $196 copayment each day for Medicare-covered days 
21 to 44; for Skilled Nursing Facility (SNF) Care days 21 to 35, which is 15 days (15 x $196 = $2940).  
 
You have been asked to pay $196 copayment each day for Medicare-covered days 21 to 44; for Skilled Nursing 
Facility (SNF) Care days 21 to 35, which is 15 days (15 x $196 = $2940). This item/service falls within the 
Skilled Nursing Facility (SNF) 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. Therefore, we decided that the Plan does not have copayment for skilled nursing 
facility (SNF) care provided on January 5, 2023, to January 28, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs a long-term acute care
facility to regain maximum function. The Plan denied your request. The Plan says the enrollee's records do not
show the need for several more weeks in the LTACH to be able to breathe independently. Services for the care
needed can be provided in another setting, such as in the current acute care facility.

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 there are no services available at the LTACH that the enrollee requires that are not
available at the current health care setting being offered by the health plan.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long-term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomographic (CT) colonography. 
 
You asked the Plan to pre-approve a CT colonography. You say that a CT colonography is medically 
necessary. The Plan denied your request. The Plan says the requested CT colonography does not meet the 
Medicare coverage criteria.  
 
The Plan follows Medicare rules. Medicare rules say that a CT colonography is covered when the criteria listed 
in the Medicare rules section of this decision are met.  
 
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 CT colonography. Our reviewer says 
that the requested CT colonography is not considered medically necessary in this case. Our physician reviewer 
found that the enrollee has reported weight loss and constipation. The enrollee had a gastroenterology (GI) 
consult and the recommended CT of the abdomen and pelvis was done on April 18, 2023 before the scheduled 
colonoscopy. The CT showed a fat containing left inguinal hernia otherwise no findings of note. The enrollee 
next had a direct colonoscopy on April 21, 2023, which was done without difficulty and revealed retained stool 
but no mass or stricture. The GI note after the colonoscopy described a plan for CT colonography but no 
rationale or justification for the requested procedure, (code 74263), was given. The medical necessity for the 
requested CT colonography has not been established in the submitted records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CT colonography have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a CT colonography.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the footrest complete assembly replacement only 
(K0045). 
 
You asked the Plan to pre-approve the footrest complete assembly replacement only. You say that the enrollee 
needs a power wheelchair. The Plan denied your request. The Plan says this item is not covered with a new 
power wheelchair. 
 
The Plan must follow Medicare rules. Medicare rules say that all replacement options and accessories provided 
at the time of initial issue of a POV are not separately billable. 
 
We looked at the file and Medicare rules. The record shows that this item is being requested at the same time as 
a new power wheelchair. Based on this information, we decided that Medicare rules for coverage of the footrest 
complete assembly replacement only have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the footrest complete assembly replacement only (K0045).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a ventilator for 6 months (E0466). 
 
You asked the Plan to pre-approve a ventilator for 6 months. You say that the services are necessary. The Plan 
denied your request. The Plan says that based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
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 ventilator for 6 months. Our reviewer 
says that the services are medically necessary. Our physician reviewer found you have been on average volume 
assured pressure support (AVAPS) with compliance and should be continued as prior. To withdrawal an 
therapy that is successful at this junction would be substandard of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator for 6 months have been met. Therefore, we decided that the Plan 
has to pre-approve a ventilator for 6 months (E0466).  
 
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.