Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mandibular partial denture (D5214) provided on December 
1, 2022. 
 
You asked the Plan to pay for 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 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 December 1, 2022. 
Therefore, we decided that the Plan does not have to pay for a mandibular partial denture (D5214) provided on 
December 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on July 6, 2021, to July 
15, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was 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 inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code A41.51, described as 
Sepsis due to Escherichia coli [E. coli]. 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 the 
inpatient hospital services at the DRG originally billed. Our reviewer says that documentation does not support 
the billed code. Our physician reviewer found that the enrollee' s condition was not sepsis as the 3rd 
international consensus conference has established, The SOFA criteria of a score >2were not met. The plan has 
correctly adjusted the billing code.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on July 6, 2021, to July 15, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
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 it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does 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 enrollees nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for spinal surgery. Medical problems are stable. There are no complex nursing or rehabilitation 
needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. 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. 
 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the standard frames provided on November 5, 2022. 
 
You asked the Plan to pay for the standard frames. You say that you were not told by a Plan representative that 
the provider is only in-network for medically necessary services. You say you were given misinformation and 
believed that the frames would be covered. The Plan denied your request. The Plan says the provider was out-
of-network 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers this item when provided by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network Based on this 
information, we decided that the Plan's rules for coverage of the standard frames have not been met. Therefore, 
we decided that the Plan does not have to pay for the standard frames provided on November 5, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from January 28, 2023, 
through January 29, 2023. 
 
You asked the Plan to pay for self-administered drugs. You say that the claim should be reprocessed. The Plan 
denied your request. The Plan says self-administered drugs do not fall under Medicare Part B coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
from January 28, 2023, through January 29, 2023.  
 
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fixed partial denture (D9120) for tooth #1 provided on 
December 13, 2022. 
  
You asked the Plan to pay for the dental service. You say that it was medically necessary for you to get the 
procedures done and you would like the Plan to help paying for the services. The Plan denied your request. The 
Plan says the denial of payment for this service is correct, because the fixed partial denture 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a fixed 
partial denture (D9120) for tooth #1 provided on December 13, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care provided on July 16, 2021. 
 
You asked the Plan to pay for home health care. You say that this payment denial contradicts your RAP claim 
being billed at $0. The Plan denied your request. The Plan says the RAP was not submitted within the required 
5-day period. 
 
The Plan must follow Medicare rules. Medicare rules say that home health agencies must submit the RAP 
within 5 calendar days of the start date or from date for each 30-day period of care.  
 
We looked at the file and Medicare rules. This RAP was not submitted within 5 calendar days of the start date 
for this period of home health. Based on this information, we decided that Medicare rules for coverage of home 
health care have not been met. Therefore, we decided that the Plan does not have to pay for home health care 
provided on July 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) described by 
code E0651. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary.  
The Plan must follow Medicare rules. Medicare rules say that a PCD is covered when specific criteria 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the submitted documentation does not 
show that you have tried and failed at least four weeks of conservative care, including regular and compliant 
use of an appropriate compression bandage system or compression garment to provide adequate graduated 
compression. The criteria for coverage are not met and the PCD is therefore not reasonable or medically 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a pneumatic compression device (PCD) described by code E0651.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom ankle-foot orthosis (AFO) described by code 
L1940 with below knee soft interface and lacer molded to patient model additions. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that an AFO and additions are covered when specific 
criteria 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the submitted progress notes to support the orthotist claims that the enrollee requires a custom AFO or that the enrollee has instability on a physical 
exam of the left ankle and requires this brace for stabilization and to benefit functionally. The services are 
therefore not reasonable or medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a custom ankle-foot orthosis (AFO) described by code L1940 with below knee soft 
interface and lacer molded to patient model additions.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a recliner with a seat lift mechanism. 
 
You asked the Plan to pre-approve the seat lift mechanism. You say that you believe that this lift chair is 
necessary for you.  The Plan denied your request. The Plan says the criteria for the requested lift chair are not 
met.  
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section 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 the seat lift mechanism. Our reviewer 
says that the documentation does not support that the criteria for the seat lift mechanism are met.   
 Our physician reviewer found the enrollee is a 74-year-old female with a medical history neuropathy, low back 
pain, carpal tunnel syndrome, osteoarthritis, and anxiety. A physical therapy evaluation dated March 1, 2023, 
indicated that the enrollee's range of motion and motor strength was within normal limits. She was noted to 
have good static and dynamic standing balance and no history of falls. She was able to ambulate in her home 
without an assistive device. The enrollee was able to independently transfer from a sitting to standing position.  
 
The enrollee does not require a power seat lift chair per guideline criteria. She can ambulate independently and 
is independent performing sit to stand transfers. 
 
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 seat lift mechanism have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a recliner with a seat lift mechanism.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repair of a power scooter (K0800). 
 
You asked the Plan to pre-approve repair of a power scooter. You say that the enrollee has PMH including 
CHF, HD and paraplegia. The repair of his electric wheelchair is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says the request for repairs to the enrollee's scooter cannot 
be covered. Per Medicare rules, repairs cannot be covered if the cost of repair is more than the cost of 
replacement and if the total cost of the repair of the serviceable backup power wheelchair does not exceed 
$1,000.00 per calendar year. 
 
The Plan must follow Medicare rules. Medicare rules say that wheelchair repairs are not covered if the cost of 
repair exceeds the cost of replacement. 
 
 
 
 We looked at the file and Medicare rules. The records show that previous repairs were obtained in the amount 
of $622.75. The records also show that the replacement cost for the wheelchair currently configured is 
$1,098.90. Therefore, the cost of requested repairs exceeds the cost of replacement of the enrollee's scooter. 
Based on this information, we decided that Medicare rules for coverage of repair of a power scooter have not 
been met. Therefore, we decided that the Plan does not have to pre-approve repair of a power scooter (K0800).
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 meets the LTACH 
requirements for admission. The Plan denied your request. The Plan says the enrollee is currently receiving 
appropriate inpatient care and does not require to be transferred. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Willowwood Meta Shock Foot (L5987). 
 
You asked the Plan to pre-approve the Willowwood Meta Shock Foot. You say that the item is medically 
necessary. The Plan denied your request. The Plan says this item exceeds the enrollee's needs. 
 
The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of knee. This 
information must be retained in the treating practitioner's or prosthetist's files. 
 
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 Willowwood Meta Shock Foot. Our 
reviewer says that the enrollee does not need this item. Our physician reviewer found the patient uses a walker 
and wheelchair which is not consistent with K3 level ambulation. 
 
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 Willowwood Meta Shock Foot have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the Willowwood Meta Shock Foot (L5987).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. 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 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. 
 
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. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically necessary. There is no arterial blood gas (ABG) done while stable to confirm chronic carbon dioxide (CO2) 
retention. If that is present, the enrollee may benefit from bilevel positive airway pressure (BiPAP) with 
average volume-assured pressure support (AVAPS) and a backup rate as an outpatient. Medicare does not 
cover a home ventilator for the treatment of obesity hypoventilation syndrome, or when used at settings that 
can be provided with BiPAP. 
 
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 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for dates of service January 1, 
2023, to January 28, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that this is medically necessary treatment and 
should be paid.  The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for dates of service January 1, 2023, to January 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99204) provided on December 15, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99204 is "Office or other outpatient visit for the 
evaluation and management of a new patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using time for code selection, 45-59 
minutes of total time is spent on the date of the encounter". 
 
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 use of code 99204 is not supported by the records provided. Our reviewer found that the enrollee was an established patient with this 
clinic on December 1, 2022. therefore a new patient code would not be appropriate to bill under the same 
facility with a different provider. 
 
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 services (99204) provided on December 15, 2022.