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

 
We decided that the Plan does not have to pay for moderate sedation services (99152) provided on June 7, 
2020. 
 
You asked the Plan to pay for the moderate sedation services. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says the documentation does not 
support the service billed. 
 
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 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
We find that CPT code 99152 is not supported in the record. Specifically, the record does not indicate the 
presence of an independent trained observer. Based on this information, we decided that Medicare rules for 
coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not 
have to pay for moderate sedation services (99152) provided on June 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 power mobility device (K0808). 
 
You asked the Plan to pre-approve the group 2 power mobility device. You say that the scooter is medically 
necessary. The Plan denied your request. The Plan says the requested scooter is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that if a Group 2 POV is provided it will be denied as 
not reasonable and necessary.  
 
We looked at the file and Medicare rules. The requested Group 2 POV is not covered. Based on this 
information, we decided that Medicare rules for coverage of the group 2 power mobility device have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a group 2 power mobility device 
(K0808).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for a venipuncture (blood draw) and laboratory test provided on August 9, 
2019. 
 
You asked the Plan to pay for lab services. You say that you developed a swollen gland while on vacation and 
needed this test to check things out. The Plan denied your request. The Plan says that the denial of payment for 
these services is correct, because this provider is out-of-network with the Plan. 
 
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. Medicare says that plans must pay for emergency and urgently needed services. The Plan contract 
says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal 
dialysis, and pre-approved care.   
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not submit any medical records for review, or any documented 
attempts to obtain medical records. These services were performed while outside of the Plan?s service area. 
Without medical records, we cannot determine whether these services meet the Medicare criteria for urgent 
out-of-area care. Therefore, the Plan has not shown that its decision to deny payment is correct or justified 
according to Medicare rules or the Plan contract. Therefore, we decided that the Plan has to pay for a 
venipuncture (blood draw) and laboratory test provided on August 9, 2019.  
 
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the claim should be paid, and the 
transfer should be allowed. The Plan denied your request. The Plan says the services are not shown to 
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 enrollee was approved for observation care at the hospital. The records support 
this as most patients will be able to be discharged the same day as the procedure without issues and do not 
require inpatient services. There were no clinical findings suggestive of the enrollee requiring hospital services 
that would likely cross 2 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on April 13, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services rendered were not a covered benefit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit provided on April 13, 2020 by an 
out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve patient lift, hydraulic or mechanical, includes any seat, 
sling, strap(s) or pad(s) (CPT Code E0630). 
 
You asked the Plan to pre-approve the DME. You say that you receive home health services, and it is hard to 
be moved around from chair to bed. You state that you are requesting a Patient Lift because you are not able to 
walk. The Plan denied your request. The Plan says the DME report did not mention or endorse the need for a 
Patient lift and there was no documentation showing that you are confined to your bed without a Patient Lift. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. The DME report did not mention or 
endorse the need for a Patient lift and there was no documentation showing you are confined to your bed 
without a Patient Lift. Therefore, we decided that the Plan does not have to pre-approve patient lift, hydraulic 
or mechanical, includes any seat, sling, strap(s) or pad(s) (CPT Code E0630).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care, first hour (99291) closed treatment of femoral 
fracture, proximal end, neck (27232) moderate (conscious) sedation services (99152) provided January 9, 2020. 
 
You asked the Plan to pay for the emergency services. You say that you have attached a copy of the record and 
expect your claim to be processed within 14 days. The Plan denied your request. The Plan says the billed 
service cannot be verified. 
 
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 find that CPT codes 27232, 99291 and 99512 are not supported in the medical record. 
Specifically, the documentation submitted shows an incorrect patient name. The medical records submitted are 
for a different patient. The plan made multiple attempts to obtain the additional information from the provider 
without success. Based on this information, we decided that Medicare rules for coverage of the emergency 
services have not been met. Therefore, we decided that the Plan does not have to pay for critical care, first hour 
(99291) closed treatment of femoral fracture, proximal end, neck (27232) moderate (conscious) sedation 
services (99152) provided January 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown - porcelain/ceramic (D2740) and core buildup, 
including any pins when required (D2950). 
 
You asked the Plan to pre-approve the dental services. You say that you are requesting review of denial of 
services. The Plan denied your request. The Plan says the services are not a covered benefit under 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. The services are not listed in the member's EOC as a covered benefit; 
therefore, the services are not covered. Therefore, we decided that the Plan does not have to pre-approve crown 
- porcelain/ceramic (D2740) and core buildup, including any pins when required (D2950).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3. 
 
You asked the Plan to pre-approve Gelsyn-3. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Gelsyn-3. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has unilateral primary osteoarthritis of the left knee. The enrollee has not trialed 
viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, requires 
these be trialed first. The documentation does not outline contraindications or reasons these medications were 
not considered. Without the support of the documentation, Gelsyn-3 is not approved, as step criteria have not 
 
 
been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Prolia. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a history of metastatic prostate cancer.  He is treated with Lupron. The 
documentation does not support that the requested use of Prolia is FDA-approved for the enrollee's diagnosis 
of metastatic prostate cancer. The medication is not supported by one of the major drug compendia or by 
clinical research that appears in a CMS-approved medical journal. Therefore, the enrollee does not meet criteria 
for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that there is no need for daily skilled therapy services and there are no daily 
skilled nursing needs. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for SNF services. 
 
 
 
 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve localized delivery of antimicrobial agents via a 
controlled release vehicle into diseased crevicular tissue, per tooth (Periodontal Chip) (D4381). 
 
You asked the Plan to pre-approve the dental services. You say that you are requesting this service because you 
feel your monthly premium payment entitles you to have all dental services covered, even if it is not a covered 
code. The Plan denied your request. The Plan says the procedure you are requesting is not a covered service. 
The Plan states they recommend you discuss alternative treatment options with your dental provider, however, 
if you elect to proceed with the periodontal chip, you will be responsible for the cost of the service. 
 
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. This service is not listed in your EOC as a covered benefit; therefore, it 
is not covered. Therefore, we decided that the Plan does not have to pre-approve localized delivery of 
antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth (Periodontal 
Chip) (D4381).
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 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 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 the enrollee is currently undergoing treatment at an inpatient rehabilitation facility 
(IRF) following a recent stroke and COViD-19 infection. The enrollee requires maximal to total assistance for 
mobility and activities of daily living (ADLs). There is no evidence that the enrollee requires acute care 
hospital (ACH) services. Therefore, transfer to a LTACH is not medically necessary or reasonable. 
 
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on March 24, 2020. 
 
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 procedure code 36215 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 36215 is selective catheter placement, arterial system; 
each first order thoracic or brachiocephalic branch, within a vascular family. 
 
We find that CPT code 36215 is not supported in the medical record. Specifically, the operative report does not 
contain documentation of a selective catheter placement into the arterial system. 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 pay for the surgical services rendered on March 24, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the bevacizumab injection rendered on May 6, 2020. 
 
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 procedure code J9035 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 J9035 is injection, bevacizumab, 10 mg. 
 
We find that CPT code J9035 is not supported in the medical record. Specifically, there is no documentation of 
an injection of bevacizumab. 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 pay for the bevacizumab 
injection rendered on May 6, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve a lumbar laminectomy/discectomy (0275T). 
 
You asked the Plan to pre-approve a lumbar laminectomy/discectomy. You say that the services are necessary. 
The Plan denied your request. The Plan says that medical necessity has not been established. Therefore, 
coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 lumbar laminectomy/discectomy. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found there is current evidence based medical literature support for the use of this 
procedure for the treatment of spinal stenosis, as compared to lumbar epidural steroid injection. In this case, 
there is an intact neurological exam despite neurogenic claudication and severe neuroforaminal stenosis. The 
combination of relatively advanced age and comorbidity of chronic obstructive pulmonary disease (COPD) 
supports medical indication for the procedure in this case. Therefore, this request for percutaneous 
laminotomy/laminectomy for decompression (MILD procedure) is considered medically reasonable and 
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 a lumbar laminectomy/discectomy have been met. Therefore, we decided that 
the Plan has to pre-approve a lumbar laminectomy/discectomy (0275T).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection procedure for sacroiliac joint, 
anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed (CPT 
Code 27096). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been 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 service. Our physician reviewer 
found the recent SI injection was November 2, 2020, and it provided greater than 75% pain relief; however, it 
has only been three (3) weeks since that injection. Medicare requires at least two (2) months between injections 
to determine effectiveness and improved function. The review has determined that the medical records 
provided do not meet the requirements listed in the LCD and Coverage Article for Medicare coverage.  
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance 
(fluoroscopy or CT) including arthrography when performed (CPT Code 27096).