Persius/hicric huggingface dataset:
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 your attending doctor says that you need to be placed 
in an acute IRF as soon as possible or you will begin to deteriorate and will not be able to regain maximum 
function. The Plan denied your request. The Plan says the IRF services requested 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record 
supports a need for physical 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. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87634 and 87640 billed for date of service 
November 28, 2022. 
 
You asked the Plan to pay for procedure codes 87634 and 87640. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says payment for code 87634 is 
bundled into payment for code 87633. Additionally, payment for code 87640 is bundled into payment for code 
87641. 
 
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 code 87634 
is a column II code to column I code 87633. Additionally, we have confirmed that code 87640 is a column II 
code to column I code 87641. The records do not support the services as separate and distinct. Based on the 
claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure codes 87634 and 87640 billed for date of service November 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve routine transport. You say that the enrollee needs this transportation to get 
to medically necessary appointments. The Plan denied your request. The Plan says routine transportation 
beyond 48 one-way trips per calendar year is not covered by the Plan. 
 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 48 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that after the enrollee receives 48 covered trips, the routine transportation benefit will be exhausted. Therefore, 
we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87798 billed for date of service January 9, 
2023.  
 
You asked the Plan to pay for procedure code 87798. You say that the test aids with diagnosis and treatment 
options. 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 87798 is 13. The MAI value for this code is 3. You billed 19 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
provided, correctly coded, and medically necessary. Based on this information, we decided that Medicare rules 
for coverage of procedure code 87798 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 87798 billed for date of service January 9, 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 enrollee's clinical condition meets full acute 
inpatient rehabilitation criteria. The Plan denied your request. The Plan says the enrollee does not meet 
Medicare guidelines for services in 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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical 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. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 receiver.  
You asked the Plan to pre-approve the Dexcom G6 receiver. You say that  the CGM is medically necessary.  
The Plan denied your request. The Plan says the enrollee does not meet the Medicare coverage criteria. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the FreeStyle Libre. Our reviewer says 
that the CGM is not medically necessary. Our physician reviewer found coverage criteria for CGM require low 
blood glucose sugar or insulin use. The enrollee does not meet criteria now for the CGM. If the enrollee is 
started on insulin or if they are having documented low blood glucose sugar, this data should be submitted and 
the case re-reviewed. 
 
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 FreeStyle Libre have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Dexcom G6 receiver.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthosis (L8702). 
 
You asked the Plan to pre-approve a MyoPro orthosis. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item is considered experimental. 
 
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 a MyoPro orthosis. Our reviewer says 
that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the MyoPro is not the standard of care this condition based on scientific evidence. There is 
insufficient evidence in the literature that the MyoPro Orthosis will improve the long term outcomes or that it 
will increase participation in bimanual activities. 
 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 MyoPro orthosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro orthosis (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the microprocessor foot (L5973). 
 
You asked the Plan to pre-approve the microprocessor foot. You say that the item is medically necessary. The 
Plan denied your request. The Plan says the documentation does not show why the member's current K3 foot, 
which is less than three years old, and therefore under warranty, needs to be replaced.  
 
The Plan follows Medicare rules. Medicare rules say that payment may be made for the replacement of a 
prosthetic device that is an artificial limb, or replacement part of a device if the ordering physician determines 
that the replacement device or part is necessary because of any of the following: 
1. A change in the physiological condition of the patient;  
2. An irreparable change in the condition of the device, or in a part of the device; or 
3. The condition of the device, or the part of the device, requires repairs and the cost of such repairs would be 
more than 60 percent of the cost of a replacement device, or, as the case may be, of the part being replaced.  
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 microprocessor foot. Our reviewer 
says that the enrollee does not need this item. Our physician reviewer found the documentation submitted does 
not reveal that there has been a change in the physiological condition of the patient, irreparable change in the 
condition of the current foot, or that the foot requires repairs. 
 
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 microprocessor foot have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the microprocessor foot (L5973).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on March 27, 2023, billed with 
procedure code 01402-AA-P2 (94 units). 
 
You asked the Plan to pay for the practitioner services provided. 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 billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 01402-AA-P2 (94 units) is anesthesia for open or surgical 
arthroscopic procedures on knee joint, total knee arthroplasty. 
 
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 practitioner services provided. Our reviewer says that documentation does not support the billed code. Our reviewer found that the units billed are not supported. The 
record states that anesthesia started at 0950 and ended at 1121, this is 91 minutes of anesthesia. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on March 27, 2023, billed with procedure code 
01402-AA-P2 (94 units).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653, and 87798 billed for date of 
service February 23, 2023. 
 
You asked the Plan to pay for procedure codes 87481, 87653, and 87798. The Plan denied your request. The 
Plan says payment for codes 87481, 87653, and 87798 are bundled into payment for code 87801. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
The file shows that a urinary tract infection panel was provided. In this case, we have confirmed that codes 
87481, 87653, and 87798 are column II codes to column I code 87801. The records do not show that the codes 
at issue were an unusual overlapping service. Based on the claim submitted, Medicare billing criteria have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure codes 87481, 87653, and 
87798 billed for date of service February 23, 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 skilled nursing facility can't provide the complex 
care that the enrollee needs. The Plan denied your request. The Plan says the IRF services requested 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical 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. 
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 30, 2022, to 
August 5, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you have billed the services at 
issue correctly. 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 for home health services that are continuing from 2021, a 
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 for the NOA which is filed for the first date in 2022 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 July 30, 2022, to August 
5, 2022.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 81292 and 81295. We 
decided that the Plan does not have to pay for the services described by procedure code(s) 81321, 81351, and 
81406.  
 
You asked the Plan to pay for procedure codes 81321, 81351, 81406, 81292 and 81295 provided on July 26, 
2022. You say that you would like the Plan to reconsider their denial of payment. The Plan says that panel 
testing should be billed using one CPT code on the claim. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 81292 and 81295.  
 
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 did not make an appeal decision for the codes listed in this 
section. The Plan must issue a determination on all appealed services within the appeal time frame. As the Plan 
forfeited its opportunity to provide a denial rationale for these services, we find that the denial of payment is 
not supported. Therefore, we decided that the Plan has to pay for the services described by procedure code(s) 
81292 and 81295.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
81321, 81351, and 81406. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the services described 
by procedure code(s) 81321, 81351, and 81406 have not been met. Therefore, we decided that the Plan does 
not have to pay for the services described by procedure code(s) 81321, 81351, and 81406. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary and mandibular partial dentures and the 
removal of torus palatinus (D5213, D5214 and D7472). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your dental benefits. 
 
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 
maxillary and mandibular partial dentures and the removal of torus palatinus (D5213, D5214 and D7472).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower partial denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your dental benefits. 
 
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, lower partial dentures are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a lower 
partial denture (D5214).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the torus mandibularis removal to be provided by an 
OON provider.  
 
You asked the Plan to pre-approve the torus mandibularis removal. You say that you have lost over 30 pounds 
from not being able to eat. The Plan denied your request. The Plan says there are in-network providers that can 
provide this service. 
 
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 
the torus mandibularis removal to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 heavy duty power wheelchair, single power 
option (K0858) and additional items and accessories (codes E1002, E1020, E1028, E2300, E2311, E2363, and 
K0108).  
You asked the Plan to pre-approve a group 3 heavy duty power wheelchair and additional items and 
accessories. You say that the documentation clearly shows the enrollee does meet the criteria for power tilt and 
it is medically necessary to meet their needs. The Plan denied your request. The Plan says the enrollee does not 
have a qualifying diagnosis causing mobility limitation for which group 3 power wheelchair is medically 
needed. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, 
myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a 
group 3 heavy duty power wheelchair, single power option (K0858) and additional items and accessories 
(codes E1002, E1020, E1028, E2300, E2311, E2363, and K0108).