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

 
We decided that the Plan does not have to pre-approve a vacuum-assisted socket system. 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says the use of vacuum pumps for residual limb volume management and moisture 
evacuation systems among amputees is unproven and not medically necessary due to insufficient evidence of 
safety and/or efficacy. 
 
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 system. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that Medicare allows for replacement of a prosthesis or prosthetic component if there is a change in the 
physiological condition of the beneficiary, there is irreparable wear of the device or a part of the device or if the 
condition of the device, or part of the device, requires repairs and the cost of such repairs would be more than 
60% of the cost of a replacement device, or the part being replaced. In this case, the you have had 
a replacement prosthesis approved. The requested device has not been shown to be superior to other standard 
treatments for the medical condition. The requested device is not 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 the system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a vacuum-assisted socket system.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 patient is requiring minimal assistance for transfers and bed mobility and lower 
body dressing. The patient is standby assistance with upper body dressing and toileting. The patient is 
ambulating one hundred (100) feet with a walker with contact guard assistance. The patient does not require the 
intensity of therapies provided an acute inpatient rehabilitation. 
 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for therapeutic continuous glucose 
monitor (cgm) provided on February 10, 2022. 
 
You asked the Plan to pay for the supply allowance for therapeutic cgm. You say that you would like the plan 
to reconsider their denial. The Plan denied your request. The Plan says the documentation does not include 
medical records that do not support the medical necessity for the items rendered. 
 
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 relevant medical records which support medical necessity for the supplies provided 
in this case. The documentation submitted did not sufficiently support the billed supply code. 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 the supply allowance for therapeutic continuous glucose monitor 
(cgm) provided on February 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a diagnostic colonoscopy provided on August 2, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for a diagnostic colonoscopy. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the services are not authorized because this provider is a 
non-network provider who does not work with the member's health plan, and the member was referred by a 
provider who also does not work with the member's plan. The Plan also says that the member's primary care 
physician did not refer for services. 
 
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 a diagnostic colonoscopy provided on August 2, 
2021, 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 arthrodesis, posterior or posterolateral technique, 
single interspace; lumbar (with lateral transverse technique, when performed) (22612). 
 
You asked the Plan to pre-approve an outpatient procedure. You say that the requested outpatient procedure is 
medically necessary. The Plan denied your request. The Plan says the requested outpatient procedure does not 
meet criteria. 
 
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 an outpatient procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found interspinous fixation devices remain experimental and investigational as it is not 
identified as widely used and generally accepted for the proposed use as reported. More research is needed. 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an outpatient procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an arthrodesis, posterior or posterolateral technique, single interspace; lumbar 
(with lateral transverse technique, when performed) (22612).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture (CPT code 97810). 
 
You asked the Plan to pre-approve acupuncture. You say that you have responded well to acupuncture (coupled 
with physical therapy) treatment has demonstrated improvement in reducing sensitivity and pain, particularly in 
roof of mouth, and severity of headache/pain unresponsive to pain. The Plan denied your request. The Plan 
says the Medicare rules have not been met. 
 
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 acupuncture have not been met. The rules say that effective for 
claims with dates of service on and after January 21, 2020, acupuncture is only covered for chronic low back 
pain. Your notes do not show that you have low back pain. Therefore, we decided that the Plan does not have 
to pre-approve acupuncture (CPT code 97810).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) and a core build-up (D2950), provided by a 
participating provider on December 29, 2021. 
 
You asked the Plan to pay for a crown and a core build-up. You say that you feel like the Plan should pay for 
more of this. The Plan denied your request. The Plan says the benefit limit for dental services has been met and 
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. The Plan covers dental 
services up to $1,000. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a crown and a core build-up have not been met. Therefore, we decided that the Plan does not have 
to pay for a crown (D2740) and a core build-up (D2950), provided by a participating provider on December 29, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on October 21, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. Based on this 
information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the genetic testing services provided on October 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided to the enrollee on November 23, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documentation does not support the units 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 01360 is "Anesthesia for all open procedures on lower 
one-third of femur." 
 
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 services at issue in 
this case were supported by the medical records. Our reviewer found that in this case, the anesthesia time billed 
= 114 minutes. An anesthesia time unit is NOT equal to 1 minute. The time units in this case would be 114 
minutes/5, for a total 7.5 units, rounded up for a total of 8 time units. The records do not support that 114 
anesthesia time units were rendered for the anesthesia services provided. 
 
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 anesthesia services provided to the enrollee on November 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an adult sized disposable incontinence product, 
brief/diaper (T4523). 
 
You asked the Plan to pre-approve incontinence supplies. You say that the enrollee suffers from immobility 
syndrome due to bilateral below knee amputation and is wheelchair dependent. The Plan denied your request. 
The Plan says Medicare only covers supplies that are used to care for a medical need to treat a disease, illness, 
or injury. The requested item is not a covered item under the enrollee's Plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve an adult sized disposable 
incontinence product, brief/diaper (T4523).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the additional visits. You say that thi sis medically necessary. The Plan 
denied your request. The Plan says more skilled treatment is not needed at this time. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the additional requested therapy generally is not accepted as specific 
and effective therapy for your condition beyond what was approved by the health plan. You have had prior 
therapy and the documentation does not reveal that you require the unique skills of a professional therapist to 
safely and effectively provide treatment, that the services can be safely and effectively performed only by a 
therapist, or by or under the supervision of a therapist. The requested services are not part of a maintenance 
program, and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, 
design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. 
You can transition to a home exercise program. 
 
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 additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve eight additional physical therapy (PT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided to the enrollee on October 18, 2021. 
 
You asked the Plan to pay for the visit. You say that this should bep aid for. The Plan denied your request. The 
Plan says the incorrect code and modifiers were submitted. 
 
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 99214 is "Office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using time for code selection, 30-39 
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 visit. Our reviewer says that the services at issue in this 
case were not supported by the medical records. Our reviewer found that the medical records indicate that the 
enrollee presented to the clinic for the spinal injection. The exam done prior would be considered part of the 
pre-op and not eligible for the billed on the same day. The spinal injection was a planned procedure. 
 
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 visit have not been met. Therefore, we decided that the Plan does not have 
to pay for an office visit provided to the enrollee on October 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care services coded 99222 provided on 
July 30, 2021. 
 You asked the Plan to pay for the initial hospital care services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services are not payable as 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, we have confirmed that code 99222 
is a column II code to column I code 32555. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the initial hospital care services coded 99222 provided on July 
30, 2021.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for emergency ambulance transportation services (A0427, A0425) 
provided on July 1, 2021. 
 
You asked the Plan to pay for emergency ambulance services. You say that these services were emergent and 
necessary and should be paid. The Plan denied your request. The Plan says that these services were provided 
while the enrollee was registered inpatient in the hospital; therefore, these services are considered patient 
transportation and are paid under the inpatient prospective payment system through the hospital and are not 
separately payable. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. While it is true that patient transportation would be paid to the hospital as part of 
the hospital payment, the Plan has not provided sufficient evidence to show that the enrollee was inpatient 
status on the date in question and that they remained inpatient at the first facility during and after this 
transportation. Without this evidence we cannot confirm that the services at issue are considered patient 
transportation. Therefore, we decided that the Plan has to pay for emergency ambulance transportation 
services (A0427, A0425) provided on July 1, 2021.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81220, 81226, 81227, 81230, 
81238, 81291, and 81335 provided on 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as 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. 
 
We find that CPT codes 81220, 81226, 81227, 81230, 81238, 81291, and 81335 are not supported in the 
medical record. Specifically, when a laboratory assays two or more genes in an enrollee in parallel, those two 
or more genes will be considered part of the same panel. A panel constitutes a single procedural code, so one 
code must be submitted for the panel. Review of the file does not support that only one code was submitted for 
the panel. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 
81220, 81226, 81227, 81230, 81238, 81291, and 81335 provided on
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, first hour (99291) provided on July 23, 2021. 
 
You asked the Plan to pay for critical care. You say that this service was necessary and was billed 
appropriately. The Plan denied your request. The Plan says this service is not supported as 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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-
74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the medical record does not 
indicate that this service was provided for 30-74 minutes. Based on this information, we decided that Medicare 
rules for coverage of critical care have not been met. Therefore, we decided that the Plan does not have to pay 
for critical care, first hour (99291) provided on July 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a compounded drug provided on January 7, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for a compounded drug. You say that you would like to request reconsideration of 
the denied claim. The Plan denied your request. The Plan says the services are not authorized because the 
provider is OON. 
 
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 a compounded drug provided on January 7, 2021 
by an out-of-network (OON) provider.