Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve application of Epifix bioengineered skin substitute 
(BSS). 
 
You asked the Plan to pre-approve the Epifix treatment. You say that the enrollee has failed other wound care 
treatments including sharp debridement, wound vac therapy, and frequent dressing changes. The Plan denied 
your request. The Plan says the enrollee has not quit smoking for the required time and has inadequate blood 
flow to the wound area. 
 
The Plan follows Medicare rules. Medicare rules say that Epifix treatments may be covered for chronic wounds 
that have failed other therapy when the other criteria noted above 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 Epifix treatment. Our reviewer says 
that the requested use of Epifix is not shown to be reasonable and necessary based on LCD guidelines.  
 
 
 
Our physician reviewer found the patient is a 70-year-old male with diagnosed foot ulcer (1.5 cm X 3.5 cm X 
0.4 cm) and diabetes being treated with medication. He has a history of revascularization but no follow-up ABI 
or pulse oxygen testing was measured following the procedure or recently to show good circulation in the foot. 
The patient also is a smoker, and recent notes did not show documentation of quitting tobacco use for at least 4 
weeks. 
 
The enrollee's smoking status does not meet criteria for this treatment. Even putting the smoking history aside, 
there was insufficient documentation of good circulation to the extremity via ankle-brachial index or pulse 
oximetry testing. 
 
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 Epifix treatment have not been met. Therefore, we decided that the Plan 
does not have to pre-approve application of Epifix bioengineered skin substitute (BSS).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the established patient home visit (99349) provided on April 
27, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the established patient home visit. You say that telemedicine does not require an 
authorization number for payment of services rendered. The Plan denied your request. The Plan says prior 
authorization was not obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
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 established patient home visit (99349) 
provided on April 27, 2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services rendered on July 24, 2019. 
 
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 codes 95907, 95885, and 95999 are 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 95907 is nerve conduction studies; 1-2 studies. The 
definition of code 95885 is needle electromyography, each extremity, with related paraspinal areas, when 
performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in 
addition to code for primary procedure). The definition of code 95999 is unlisted neurological or 
neuromuscular diagnostic procedure. 
 
We find that CPT codes 95907, 95885, and 95999 are not supported in the medical record. Specifically, the 
technical report does not include documentation of nerve conduction studies of 1-2 studies to support code 
95907. The technical report does not include documentation of limited needle electromyography to support 
code 95885. The technical report does not include documentation of an unlisted neurological or neuromuscular 
diagnostic procedure to support code 95999. 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 
services rendered on July 24, 2019.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on January 21, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was 
submitted after the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until January 29, 2020. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the services provided on January 21, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel rendered on October 7, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure 
code 81479. 
 
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 Guardant360 panel rendered on October 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up on tooth #6 (D2950) and a partial upper 
denture (D5211). 
 
You asked the Plan to pre-approve core build up on tooth #6 and a partial upper denture. You say that the 
requested services are necessary. The Plan denied your request. The Plan says based on the documentation 
provided, coverage criteria has not been met. 
 
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. The Plan covers one of 
(D5110, D5130, D5211, D5213), once per 60 months. Core build up is not a covered benefit.  
 
We looked at the file and Medicare rules. The record shows that you received a partial upper denture on August 
9, 2018. Based on this information, we decided that the Plan's rules for coverage of core build up on tooth #6 
and a partial upper denture have not been met. Therefore, we decided that the Plan does not have to pre-
approve core build up on tooth #6 (D2950) and a partial upper denture (D5211).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Medtronic continuous glucose monitor (CGM)/insulin 
pump device. 
 
You asked the Plan to pre-approve the Medtronic CGM/insulin pump. You say that this should be approved. 
The Plan denied your request. The Plan says there are other brands of insulin pump that can be covered by the 
Plan. A request can be considered for a CGM that is approved as a therapeutic device as well. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage is only available for CGM devices 
which meet the definition of a therapeutic CGM. 
 
In this case, the CGM function of the requested device is not approved as a therapeutic CGM. As such, this 
device does not meet the criteria for coverage. Therefore, we decided that the Plan does not have to pre-
approve a Medtronic continuous glucose monitor (CGM)/insulin pump device.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for the continued SNF services provided from August 21, 2019, to August 30, 2019. You asked the Plan to pay for SNF care. You say that the continued stay was medically necessary and appropriate for the enrollee. The Plan denied your request. The Plan says that the enrollee was no longer benefiting from daily skilled therapy services after August 20, 2019.

The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal.

We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or more days before August 20, 2019. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the Plan has to pay for the continued SNF services provided from August 21, 2019, to August 30, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Electro convulsive Therapy provided out of network on 
October 17, 2019. 
 
You asked the Plan to pay for this service. You say that this service should be covered by the Plan. The Plan 
denied your request. The Plan says your out of network provider did not submit medical records to show this 
treatment was medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. You did not have prior authorization for out of network care. Your provider was 
asked to submit medical records to demonstrate medical necessity for this treatment, but did not response.  
Therefore, we decided that the Plan does not have to pay for Electro convulsive Therapy provided out of 
network on October 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Synvisc injection you had on March 
18, 2020. 
 
You asked the Plan to waive the coinsurance for the Synvisc injection. You say that you did not think you had 
any cost sharing unless you were admitted to the hospital. The Plan denied your request. The Plan says you 
were charged this coinsurance correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part-B covered drugs.  
 
You have been asked to pay 20% coinsurance for the Synvisc injection. The Synvisc injection falls within the 
Medicare Part-B covered drugs benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for 
the Synvisc injection you had on March 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network 
provider from January 18, 2019, to December 2, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the 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 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 services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided to you by an out-of-network provider from 
January 18, 2019, to December 2, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 70551) provided on June 7, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a column II 
code. 
 
The Plan must follow Medicare rules. Medicare rules say that if a provider reports the two codes of an edit pair, 
the column two code is denied, and the column one code is eligible for payment. Procedure code 70551 is part 
of an edit pair with procedure code 70546. Procedure code 70546 is a column one code, and procedure code 
70551 is a column two code. Procedure code 70546 has been billed on this date of services, which means that 
procedure code 70551 is not eligible for payment. Therefore, we decided that the Plan does not have to pay for 
the services (CPT 70551) provided on June 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the shoulder. 
 
You asked the Plan to pre-approve the MRI. You say that you would like reconsideration because the MRI is 
medically necessary. The Plan denied your request. The Plan says this test is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 the MRI. Our reviewer says that 
documentation does not include a detailed history and physical examination, summary of treatments trial, 
previous imaging studies, or a differential diagnosis and treatment plan based on imaging result. Our physician 
reviewer found without this documentation, medical necessity cannot be determined. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an MRI of the shoulder.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital services you received 
from March 13, 2020 through March 16, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that while you were in 
the hospital, a representative from the hospital came into your room and told you that all of the expenses for 
your care would be covered. The Plan denied your request. The Plan says you were charged this copayment 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $290 
copayment per day for days 1-6 for inpatient hospital care.  
 
You have been asked to pay a $290 copayment per day for the inpatient hospital services. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. The Plan cannot be held responsible for 
incorrect information given to you by an out-of-network hospital. Therefore, we decided that the Plan does not 
have to waive the copayment for the inpatient hospital services you received from March 13, 2020 through 
March 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total hip arthroplasty (27130). 
 
You asked the Plan to pre-approve the total hip arthroplasty. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says documentation of advanced joint disease 
by imaging has not been provided. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the total hip arthroplasty. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found advanced joint disease is not clearly demonstrated by radiographic supported 
evidence or magnetic resonance imaging (MRI) supported evidence of subchondral cysts, subchondral 
sclerosis, periarticular osteophytes, joint subluxation, joint space narrowing, or avascular necrosis. 
 
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 total hip arthroplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a total hip arthroplasty (27130).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on June 4, 2020. 
 
You asked the Plan to pay for the domiciliary or rest home visit. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a domiciliary or rest home visit provided on June 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for thromboendarterectomy (35355 and 35302) and 
embolectomy (34201) provided on July 21, 2019. 
 
You asked the Plan to pay for the thromboendarterectomy and embolectomy. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation 
submitted does not support the services 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 35355 is thromboendarterectomy, including patch graft, 
if performed; iliofemoral. 
 
The CPT Code Manual definition of code 35302 thromboendarterectomy, including patch graft, if performed; 
superficial femoral artery. 
 
The CPT Code Manual definition of code 34201 is embolectomy or thrombectomy, with or without catheter; 
femoropopliteal, aortoiliac artery, by leg incision.  
 
 
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 thromboendarterectomy and embolectomy. Our reviewer 
says that CPT codes 35355, 35302 and 34201 do not meet criteria for billing or reimbursement consideration. 
Our reviewer found the documentation does not describe a femoral endarterectomy. 
 
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 thromboendarterectomy and embolectomy have not been met. Therefore, we 
decided that the Plan does not have to pay for thromboendarterectomy (35355 and 35302) and embolectomy 
(34201) provided on July 21, 2019.
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 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. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital on October 2, 2020, after a fall with resulting hip fracture. The physical therapy note states that she 
needs modified assist to stand, sit, lie down, and for chair-to-bed transfers. The enrollee does not require the 
intensity of services provided at an IRF.  Specifically, the enrollee is not shown to be able to perform 15 hours 
per week of rehabilitative services or to require regular physician evaluation. 
 
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 pay for continuous glucose monitor (CGM) supplies (K0553) 
provided on March 22, 2020. 
 
You asked the Plan to pay for CGM supplies. You say that this was billed correctly. The Plan denied your 
request. The Plan says a proof of delivery has not been submitted. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. There is not an 
itemized delivery invoice for the supplies at issue. Furthermore, the delivery ticket included in the file shows a 
shipping date of February 14, 2020, and a delivery date of February 21, 2020, while the supplies at issue were 
billed for March 22, 2020. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for continuous 
glucose monitor (CGM) supplies (K0553) provided on March 22, 2020.