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

 
We decided that the Plan does not have to pay for the medical services provided on August 1, 2022, billed with 
codes 93454 and 99152. 
 
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 code 93454 is not separate and distinct from the Column 1 code, and 99152 is not supported due 
to no independent observer documented. 
 
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 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 the procedure report does not 
support modifier -59 for CPT 93454. The medical record does not support a distinct procedural service; therefore, this procedure cannot be verified. in terms of CPT 99152, presence of an independent trained 
observer to assist in monitoring of the patient's level of consciousness and physiological status in not 
documented and therefore this code cannot be verified. 
 
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 the medical services provided on August 1, 2022, billed with codes 93454 and 99152.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve TP53 genetic testing (81352). 
 
You asked the Plan to pre-approve TP53 genetic testing. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that clinical symptoms and diagnosis of LFS usually 
occur prior to Medicare eligibility and TP53 carrier testing is not a covered benefit. Based on this information, 
we decided that Medicare rules for coverage of TP53 genetic testing have not been met.  Therefore, we decided 
that the Plan does not have to pre-approve TP53 genetic testing (81352).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 29, 
2021, through October 30, 2021.  
You asked the Plan to pay for acute inpatient hospital care. You say that you are requesting reconsideration of 
recoupment. The Plan denied your request. The Plan the inpatient stay was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case.  Our 
physician reviewer found the record did not show that at the time of inpatient admission the admitting 
physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency 
department and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from October 29, 2021, through 
October 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the enteral formula (B4150) provided on December 14, 2022. 
 
  You asked the Plan to pay for the enteral formula. You say that you would like this claim to be reprocessed, as 
it was denied in error and billed with the correct BO modifier. The Plan denied your request. The Plan says the 
procedure modifier was invalid on the date of service. The Plan also says this should be billed with the 
appropriate code for the service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pay for are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them.  Therefore, we decided that the Plan 
does not have to pay for the enteral formula (B4150) provided on December 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic and retainer crown (D6245, D6740). 
 
You asked the Plan to pre-approve the dental services. You say that the items should be covered as the enrollee 
disagrees with the denial. The Plan denied your request. The Plan says the items denied correctly as the 
enrollee does not meet the clinical requirements to be approved. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the dental services. Our reviewer says 
that the item is not medically necessary. Our physician reviewer found that the documentation provided 
indicates that the enrollee does not meet the criteria for coverage for a fixed bridge replacing missing tooth #12. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a pontic and retainer crown (D6245, D6740).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics.  
 
You asked the Plan to pre-approve foot orthotics. You say that the enrollee needs these orthotics for low back 
pain. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
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.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that SNF care is a medical necessity for you. The Plan 
denied your request. The Plan says rules for SNF care have not been met because the care you are requesting is 
custodial. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines.  Our 
physician reviewer found that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
March 10, 2022.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable.  Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service March 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a 4 wheeled power scooter. 
 You asked the Plan to pre-approve a power scooter. You say that you are in need of a new power scooter, and 
you are being told the Plan will only cover the 3 wheeled scooter. The Plan denied your request. The Plan says 
there is not enough information to determine if member would meet criteria for a 4-wheel scooter at this time. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that the record does not contain a valid physician order or relevant medical records which 
support medical necessity for the supplies provided in this case. The record shows that the Plan made several 
attempts to obtain the necessary documentation without success. This means that Medicare rules for coverage 
of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a 4 wheeled 
power scooter.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve occupational therapy to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve occupational therapy with an out-of-network provider. You say that you 
need to go to this location for therapy as they have better equipment. The Plan denied your request. The Plan 
says these services are available in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
   
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
occupational therapy to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided on August 11, 2022, billed with 
codes 81340 and 81342. 
 
You asked the Plan to pay for the testing services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim for this molecular pathology service did 
not include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the testing services 
provided have not been met. Therefore, we decided that the Plan does not have to pay for testing services 
provided on August 11, 2022, billed with codes 81340 and 81342.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for observation services provided from January 2, 2022, to  
January 5, 2022. 
 
You asked the Plan to pay for the observation services. You say that the Plan originally paid the claim on 
January 27, 2022, then the Plan recouped the payment on December 22, 2022. You say the corrected claim was 
rebilled on December 28, 2022, which was well within the time limit. The Plan denied your request. The Plan 
says that the member is not responsible for this charge, because the claim was not filed within the required time 
limit. 
 
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. Specifically, the Plan has not provided documentation to substantiate their denial 
that the claim was filed beyond the Medicare time limit. Therefore, we decided that the Plan has to pay for 
observation services provided from January 2, 2022, to January 5, 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: Unfavorable

 
We decided that the Plan does not have to pre-approve the seat elevator (E2300) and transit option (K0108). 
 
You asked the Plan to pre-approve the seat elevator  and transit option. You say that the items are medically 
necessary. The Plan denied your request. The Plan says these items are not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured.  Therefore, we 
decided that the Plan does not have to pre-approve the seat elevator (E2300) and transit option (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics.  
 
You asked the Plan to pre-approve foot orthotics. You say that the enrollee needs this item for chronic knee 
pain. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontic - porcelain fused to high noble metal (D6240) 
Tooth #3 and 30 and retainer crown - porcelain fused to high noble metal (D6750) Tooth #2, 4, 29 and 31. 
 
You asked the Plan to pre-approve dental services. You say that you do not agree with the services being 
denied. The Plan denied your request. The Plan says the request for a does not meet medical necessity criteria. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers dental 
services when the services are medically necessary and reasonable.  
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve dental services. Our physician reviewer 
found in this instance both teeth to be replaced are posterior teeth, thereby disqualifying the coverage request as 
coverage would be limited to missing anterior teeth and only in limited circumstances. The plan criteria has not 
been met for either bridge (2-4 or 29-31) being requested. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of dental services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve pontic - porcelain fused to high noble metal (D6240) Tooth #3 and 30 and retainer crown - 
porcelain fused to high noble metal (D6750) Tooth #2, 4, 29 and 31.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0444-XU billed for date of service October 
20, 2022.  
 You asked the Plan to pay for procedure code G0444-XU. You say that you have submitted a corrected claim. 
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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code G0444-XU is 1. The MAI value for this code is 2. You billed 2 units of 
this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code G0444-XU have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code G0444-XU billed for date of service October 20, 2022.   
 
Please note- it appears as though you were attempting to submit a corrected claim instead of a second billing of the code 
in dispute.  You will need to contact the Plan directly regarding the submission of a corrected claim.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a chair (to use with a separately reviewed seat lift 
mechanism). 
 
You asked the Plan to pre-approve a chair. You say that you need this chair so you can leave the assisted living 
facility and go home. The Plan denied your request. The Plan says a chair is not covered as durable medical 
equipment as it is a piece of furniture and not primarily and customarily used to serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured.  Therefore, we 
decided that the Plan does not have to pre-approve a chair (to use with a separately reviewed seat lift 
mechanism).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on August 8, 2021, to 
September 14, 2021. 
 
You asked the Plan to pay for the inpatient hospital services provided. You say that the claim was billed 
correctly and should be paid. The Plan denied your request. The Plan says the requested documentation needed 
for review has not been provided. 
 
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 the inpatient hospital services provided 
have been met. Specifically, an itemized bill summary has not been provided for review. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital services provided on August 8, 2021, to September 14, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical nutrition therapy services. 
 
You asked the Plan to pre-approve medical nutrition therapy services. You say that you are pre-diabetic. You 
also say that this should be approved. The Plan denied your request. The Plan says the requested services are 
not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does 
not have to pre-approve medical nutrition therapy services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
December 28, 2022.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable.  Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service December 28, 2022.