Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services provided on March 23, 2022, billed with 
codes 37253 and 75710. 
 
You asked the Plan to pay for the services as billed. You say that the services rendered should be paid due to 
medical necessity. The Plan denied your request. The Plan says these services were not coded appropriately  
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 CPT definition of code 37253 is intravascular ultrasound, (noncoronary vessel) during diagnostic 
evaluation and/or therapeutic intervention, including radiological supervision and interpretation, for each 
additional noncoronary vessel (listed separately in addition to code for primary procedure). 
 
In this case, we have confirmed that code 75710 is a column II code to column I code 37225; however, 75710 
was billed with a modifier.  
 
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 as billed. Our reviewer says that the records do 
not support payment of either code at issue in this case. Our reviewer found for 37253, the operative report 
does not describe an intravascular ultrasound procedure per the NCCI guidelines. This procedure code cannot 
be verified due to lack of documentation. In addition, the use of a modifier for code 75710 is not supported. 
This is performed on the left leg along with code 37225. This would be considered bundled and not separately 
reportable. 
 
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 as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the surgical services provided on March 23, 2022, billed with codes 37253 and 75710.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve therapy services. You say that you need physical therapy as soon as possible 
and are limited to travel. The Plan denied your request. The Plan says these services are available with in-
network providers. 
 
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is 
considered accessible to an enrollee if contract providers are available within reasonable distance and travel 
time from the enrollees home. The Plan says that enrollees must use contract providers.  
 The provider is a non-contract provider. We were able to confirm that the Plan has contract providers located 
within reasonable distance and travel time from your home who can provide therapy services. Under Medicare 
rules, this means that contract providers are accessible to you. Therefore, we decided that the Plan does not 
have to pre-approve physical therapy services provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on February 16, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON physician services. You say that this was medically necessary care. The 
Plan denied your request. The Plan says this was a routine visit, and no authorization was requested for OON 
care. 
 
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 had network providers 
available who could have provided 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 physician services provided on February 16, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit and consultation (99213, 99243) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit and consultation. You say that you are requesting a follow up 
visit with the provider who put in your pacemaker when you were inpatient. The provider the Plan is requesting 
is too far for you to drive. The Plan denied your request. The Plan says you must receive your care from a 
network provider. 
 
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 
an office visit and consultation (99213, 99243) to be provided by an out-of-network (OON) provider.
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 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 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 medically necessary. Our physician reviewer found the enrollee was 
admitted to the hospital on August 6, 2022 with chronic hypoxic respiratory failure due to chronic obstructive 
pulmonary disease (COPD) exacerbation, severe pulmonary hypertension, and COVID-19 infection. Per the 
medical records dated August 23, 2022 he remains hemodynamically stable ob baseline oxygen and completed 
a course of antibiotics. There is no documentation indicating medical necessity for LTACH services. The 
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at 
the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no 
services available at the LTACH that the enrollee requires that are not available at the health care setting being 
offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says the rules for SNF coverage have not been 
met. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not medically reasonable and necessary. Our physician reviewer found based on the 
documentation provided, the enrollee does not have documented skilled nursing needs. The enrollee does not 
have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a 
maintenance program or to prevent deterioration of the enrollees condition. The enrollees care needs appear 
to be custodial and can, as a practical matter, be provided at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network gastroenterologist. 
 
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 available from network providers. 
 
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 
a referral to an out-of-network gastroenterologist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve teeth extractions (D7210), removal of residual tooth 
roots (D7250), bone replacement graft for ridge preservation per site (D7953) and therapeutic parenteral drugs, 
two or more administrations, different meds (D9612). 
 
You asked the Plan to pre-approve dental services. You say that you have been waiting months for these 
services to get approved and are getting weaker. The dentist will not sign off for surgery because you have too 
much of an infection in your mouth. The Plan denied your request. The Plan says your benefit for the requested 
teeth extractions have already been exhausted. The Plan also says the removal of residual tooth roots, bone 
replacement graft and therapeutic parenteral drugs are not listed and therefore 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 Plans coverage rules apply in this case. The Plan covers 8 teeth 
extractions per calendar year.  
 
We looked at the file and Medicare rules. The records show that you requested 15 total extractions. The EOC 
confirms that you are allowed 8 extractions per calendar year, therefore, the remaining extractions are not 
covered. Though the Plan offers a dental benefit in excess of Medicare coverage, the remaining requested items 
or services are not among those covered under this benefit. Based on this information, we decided that the 
Plan's rules for coverage of dental services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve teeth extractions (D7210), removal of residual tooth roots (D7250), bone replacement graft 
for ridge preservation per site (D7953) and therapeutic parenteral drugs, two or more administrations, different 
meds (D9612).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve these services. You say that you had a stroke and need a power device. The 
Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a Group 3 power wheelchair. The Group 3 power wheelchair serves the same 
purpose as the requested power scooter. Therefore, we decided that the Plan does not have to pre-approve a 
power scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for additional routine transportation trips. 
 
You asked the Plan to provide coverage for additional routine transportation trips. You say that you go to 
dialysis three times a week and you need three one-way rides per week to drop you off at your dialysis 
appointments, and a family member can pick you up. The Plan denied your request. The Plan says the Plan 
provides 48 one-way rides, with a 50-mile maximum distance per one-way ride, to routine (non-emergency) 
medical care and other health care related locations (such as to the pharmacy or specialist appointments) per 
calendar year. 
 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.  
 
We looked at your request, the records in the case file, and the rules. The file shows that the Plan provides up to 
48 one-way rides per year. Therefore, we decided that the Plan does not have to provide coverage for additional 
routine transportation trips.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Novolog Flexpen. 
 
You asked the Plan to pre-approve these services. You say that the enrollee is stable on the medication. The 
Plan denied your request. The Plan says self-administered drugs are not covered. 
 
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 pre-approve Novolog Flexpen.  
 
Benefits for these services 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prostate artery embolization services. 
 
You asked the Plan to pre-approve prostate artery embolization services. You say that this procedure is 
considered medically necessary. The Plan denied your request. The Plan says medical studies have not proven 
that this service is helpful for the treatment of the enrollee's health problem. 
 
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 prostate artery embolization services. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found prostate artery embolization is not medically reasonable and necessary. 
Prostatic arterial embolization (PAE) is considered an experimental technique to treat symptomatic benign 
prostatic hyperplasia. Very limited studies have demonstrated possible short-term safety and efficacy. The most 
recent American Urological Association guidelines do not recommend this procedure outside of a clinical trial 
setting due to the heterogeneity in the available literature and safety concerns regarding radiation exposure, 
postembolization syndrome, vascular access, technical feasibility, higher clinical failure rate compared with 
more traditional methods (e.g., transurethral resection of the prostate).  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prostate artery embolization services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve prostate artery embolization services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable gaseous oxygen system, rental and portable 
oxygen contents and a gaseous and oxygen concentrator (E0431, E0443, E1390). 
 
You asked the Plan to pre-approve a portable gaseous oxygen system, rental and portable oxygen contents and 
a gaseous and oxygen concentrator. You say that you disagree with the denial and are requesting 
reconsideration. The Plan denied your request. The Plan says the enrollee has been using oxygen since August 
2019. After 36 months, the vendor is required to provide contents and service for months 37-60. Also, 
according to the guidelines, code E0443 is not able to be approved with code E1390. 
 The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a portable gaseous oxygen system, rental and portable oxygen contents and a gaseous and oxygen 
concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable 
gaseous oxygen system, rental and portable oxygen contents and a gaseous and oxygen concentrator (E0431, 
E0443, E1390).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve the oral surgery services provided on April 26, 2021, billed with 
codes 41899, 41830, and 88311. 
 
You asked the Plan to pre-approve the oral surgery. You say that this should be paid. The Plan denied your 
request. The Plan says that a review of the initial denial was not performed for these codes as the time frame 
was missed. 
 
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 the oral surgery. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found a review of the documentation indicates that the cause of the osteonecrosis was a side effect of 
the administration of a medication to treat the patient's prostate cancer. The cause is medical in nature and not 
related to any treatment of a dental condition. The treatment provided was for a medical condition. 
 
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 oral surgery have been met. Therefore, we decided that the Plan has to pre-
approve the oral surgery services provided on April 26, 2021, billed with codes 41899, 41830, and 88311.  
 
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 pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says based on Medicare guidelines and the information about the enrollee's condition, 
the enrollee does not meet the requirements. 
 
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 based on the documentation provided, the health Plans denial should be upheld. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to 
require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollees care 
needs can be met at a lower 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 IRF admission and services.