Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care visit coded 99291 provided on June 6, 2021. 
 
You asked the Plan to pay for the critical care visit. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 documentation submitted 
did not support a critical care visit of 30-74 minutes. The documentation did not include the time spent 
providing the service. Based on this information, we decided that Medicare rules for coverage of the critical care visit have not been met. Therefore, we decided that the Plan does not have to pay for the critical care visit 
coded 99291 provided on June 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377) with harness (E2313) 
and electronic connection (E2311), a tilt power seating system (E1002), a manual swingaway (E1028) and a 
cushioned headrest (E0955) for a power wheelchair. 
 
You asked the Plan to pre-approve an expandable controller with harness and electronic connection, a tilt 
power seating system, a manual swingaway and a cushioned headrest. You say that the requested items are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the request is not medically 
necessary. 
 
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 expandable controller with harness 
and electronic connection, a tilt power seating system, a manual swingaway and a cushioned headrest. Our 
reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the provided records do not support that the enrollee is high-risk for skin 
breakdown and is unable to perform a functional weight shift (the enrollee walks short distances with a cane) or 
has a history of pressure ulcer(s) or has had skin flap surgery. Records do not document that the enrollee 
performs bladder self-catheterization or has increased muscle tone or spasticity. As the power tilt does not meet 
criteria, the cushioned headrest does not meet criteria. 
 
 Furthermore, the provided records document that the enrollee has 3/5 to 3+/5 upper extremity strength and is 
independent with eating, thus indicating that the enrollee has adequate upper extremity strength and function to 
operate the wheelchair's power options with their own switches. As the expandable controller does not meet 
criteria, the swingaway hardware does not meet criteria. 
 
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 expandable controller with harness and electronic connection, a tilt power 
seating system, a manual swingaway and a cushioned headrest have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an expandable controller (E2377) with harness (E2313) and electronic 
connection (E2311), a tilt power seating system (E1002), a manual swingaway (E1028) and a cushioned 
headrest (E0955) for a power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant 
(D6010), bone graft at time of implant placement (D6104), and removal of residual tooth roots (D7250) 
provided on May 11, 2022. 
 
You asked the Plan to pay for the endosteal implant, bone graft and tooth extraction. You say that dental 
services were necessary due to medical issues. The Plan denied your request. The Plan says the cost sharing has 
been applied correctly to the removal of residual tooth roots. The remaining services at issue are not covered 
under your benefits. 
 
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.  
You have been asked to pay $98.49 ($196.98 allowed amount x 50% coinsurance = $98.49) for the tooth 
extraction. This service is included in your dental benefits with 50% coinsurance. 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. Though the Plan offers a dental benefit in excess of 
Medicare coverage, the endosteal implant and bone graft are not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pay for the surgical placement of implant body: endosteal 
implant (D6010), bone graft at time of implant placement (D6104), and removal of residual tooth roots 
(D7250) provided on May 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93320 and 93321 provided on May 27, 
2022. 
 
You asked the Plan to pay for procedure codes 93320 and 93321. You say that the medical records support the 
billing of codes 93320 and 93321 provided on May 27, 2022. The Plan denied your request. The Plan says the 
medical records do not support the billing of codes 93320 and 93321 provided on May 27, 2022.  
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 93320 is Doppler echocardiography, pulsed wave and/or 
continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging); 
complete. The definition of code 93321 is Doppler echocardiography, pulsed wave and/or continuous wave 
with spectral display (List separately in addition to codes for echocardiographic imaging); follow-up or limited 
study (List separately in addition to codes for echocardiographic imaging). 
 
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 procedure codes 93320 and 93321. Our reviewer says that 
the medical records do not support the billing of codes 93320 and 93321 provided on May 27, 2022. Our 
reviewer found review of submitted records does not confirm performance of these procedures, although it 
would have been reasonable to have carried them out in light of the mitral valve procedure on the same day. In 
summary, documentation does not support the authorization for billing of echocardiographic procedures 93320 
and 93321. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 93320 and 93321 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 93320 and 93321 provided on May 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 989 units of treatment with 3D radiation (77014, 77387, 
77412). 
 
You asked the Plan to pre-approve radiation treatment. You say that the requested services are medically 
necessary. The Plan denied your request. The Plan says anything over 10 units is not medically necessary. 
 
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 3D radiation. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that more than 10 fractions is not medically necessary and not supported by the medical 
records. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 3D radiation have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 989 units of treatment with 3D radiation (77014, 77387, 77412).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 20, 2022, billed with 
codes 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, and 87798. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says panel testing should be billed using one 
CPT code on the claim. 
 The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
January 20, 2022, billed with codes 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, and 
87798.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve physical therapy. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says the enrollee must receive their care from a network provider (for more 
information about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-
network provider (a provider who is not part of our plans network) will not be covered. 
 
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 
physical therapy to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a reduction mammography surgery. 
 
You asked the Plan to pre-approve a reduction mammography surgery. You say that this surgery is medically 
necessary. The Plan denied your request. The Plan says your PCP office confirmed that you have not been seen 
by a surgeon and that no physician has ordered the requested surgery. Medicare does not cover diagnostic or 
corrective services by a chiropractor. Therefore, a chiropractor cannot order surgery. The Plan is locating a 
participating 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. 
 
We looked at the Plans rules and the Medicare rules. The file shows that your PCP confirmed that you have 
not been seen by a surgeon and that no physician has ordered the requested surgery. Medicare does not cover diagnostic or corrective services by a chiropractor. Therefore, a chiropractor cannot order surgery. The Plan is 
locating a participating provider. The Plan has network providers available who can provide the services at 
issue in this appeal. We found no exception that would require the Plan to pre-approve these services. 
Therefore, we decided that the Plan does not have to pre-approve a reduction mammography surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic care provided on August 23, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for chiropractic care. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says the enrollee must receive their care from a network provider (for more 
information about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-
network provider (a provider who is not part of our plans network) will not be covered. 
 
  
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 chiropractic care provided on August 23, 2022, by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
comprehensive oral evaluation (D0150)
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs to be discharged to an 
appropriate level of care. The Plan denied your request. The Plan says an LTACH admission is not medically 
necessary, and the enrollee can safely receive the care they need in another setting. 
 
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 that the enrollee is more stable and should only require short-term additional acute 
care services that can safely be administered at the current facility. The enrollee does not require services at the 
LTACH that are not already available at the current facility. 
 
   
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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that this item is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the requested ventilator is not medically 
reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the requested home ventilator is not medically reasonable and necessary. Our physician reviewer found a 
home ventilator is not medically necessary. This patient has COPD, with a recent hospitalization for an 
exacerbation. Arterial blood gas tests were consistent with acute on chronic hypercarbic respiratory failure.  
The patient may benefit from bilevel positive airway pressure with average volume-assured pressure support during sleep; this has not been tried and shown to fail as an outpatient. Medicare does not cover a home 
ventilator when used in this function. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo (J2777). 
 
You asked the Plan to pre-approve Vabysmo. You say that trying Avastin would be going backwards for the 
enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drug, 
Avastin. 
 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 Vabysmo. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed the required drug. The reviewer found that there is no indication 
that the plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. 
Therefore, the reviewer found that the step therapy 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 Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vabysmo (J2777).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) services to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve the physical therapy (PT) services. You say that your PCP referred you to 
this facility. The Plan denied your request. The Plan says services from non-participating providers are not 
covered unless they are authorized before the services are provided. 
 
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 
physical therapy (PT) services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on June 16, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says this cost sharing was charged 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 $25 
copayment per visit to a specialist. Covered services include consultation, diagnosis, and treatment by a 
specialist. 
 
You have been asked to pay a $25 copayment for office visit. This item/service falls within the 
Physician/practitioner services, including doctor's office visits 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 copayment for office visit on June 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on August 01, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of our plans network) will not be covered. 
 
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 lab testing provided on August 01, 2022, by an 
out-of-network (OON) provider.