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

 
We decided that the Plan does not have to pre-approve revascularization. 
 
You asked the Plan to pre-approve revascularization. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that PTA and stenting of vessels is covered only when all 
criteria 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 revascularization. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the documentation does not 
support the medical necessity of the procedures in question. The symptoms documented suggest other 
etiologies involved including the patient's history of neuropathy. The enrollee is also documented to have full 
and equal pedal pulses bilaterally and the duplex suggests only isolated anterior tibial artery disease. No sign of 
limb threat is documented. No ankle brachial index (ABI) or toe pressures are documented. Tibial artery 
intervention in the absence of limb threat has a potential to do more harm than good. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of revascularization have not been met. Therefore, we decided that the Plan does 
not have to pre-approve revascularization.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional anesthesia services (procedure code 00400) 
provided to the enrollee on May 18, 2022. 
 
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 this is suspected as a duplicate. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 There is no evidence that CPT 00400 was rendered twice in this case. 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 additional anesthesia services (procedure code 00400) provided to the enrollee on May 18, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6240) and a retainer crown (D6750). 
 
You asked the Plan to pre-approve a pontic and a retainer crown. You say that you need the requested bridge 
because you are missing teeth and are not able to chew properly. You say that the panoramic x-ray provided 
supports the need for the requested services. The Plan denied your request. The Plan says in order to approve a 
bridge, you must be missing only one upper front tooth or only two lower front teeth. The Plan says that the 
two lower front teeth must be next to each other, and you cannot be missing any of your back teeth. The Plan 
says that their dentist looked at the x-rays that were sent and found that you are missing other teeth. 
 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 a pontic and a 
retainer crown when the services are medically necessary and reasonable.  
 
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 pontic and a retainer crown. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found fixed bridges are 
medically necessary when being used for the replacement of a single missing maxillary anterior tooth or two 
adjacent mandibular posterior teeth if there are no missing posterior teeth. In this case, teeth #4 and #5 are 
posterior teeth being replaced. The requested dental services are not considered medically reasonable and 
necessary in this case.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a pontic and a retainer crown have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a pontic (D6240) and a retainer crown (D6750).
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 enrollee's needs extra care because they are not 
fully recovered from their injuries they sustained. The Plan denied your request. The Plan says an IRF 
admission is not medically necessary, and the enrollee can receive the care they need in another setting. 
 
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 that the enrollee does not meet criteria for admission to an acute inpatient 
rehabilitation facility. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require 
an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee can 
receive further services 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 acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 15, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services are not 
included in the dialysis rate. The Plan denied your request. The Plan says Medicare does not separately pay for 
ESRD-related laboratory testing. 
 
 
 
 
 The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on June 15, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the eyeglasses and frames provided by an out-of-
network provider on July 29, 2022. 
 You asked the Plan to pay more for the eyeglasses and frames. You say that you have a $200.00 allowance for 
glasses. You say you should not have a $72.00 cost share. The Plan denied your request. The Plan says the 
claim processed correctly. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when provided by an out-of-network provider. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid 60% of the billed amount which is more 
than the 50% of the allowed amount for the services. Based on this information, we decided that the Plan's rules 
for coverage of the eyeglasses and frames have not been met. Therefore, we decided that the Plan does not have 
to pay more for the eyeglasses and frames provided by an out-of-network provider on July 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the upper and 
lower abdomen. 
 
You asked the Plan to pre-approve CT scan services. You say that this imaging is medically necessary for your 
condition. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CT scan services. Our reviewer says 
that the requested CT scan services are not medically reasonable and necessary. Our physician reviewer found 
that the record indicates that you have diarrhea and weight loss. The record indicates that colonoscopy is 
normal but initial laboratory studies have not yet been completed. The provided records do not indicate the 
medical necessity or reasonableness, as defined by Medicare rules, of the requested service. The elements of 
the coverage criteria are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT scan services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a computed tomography (CT) scan of the upper and lower abdomen.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on July 21, 
2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that this should be covered. 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 $35 
copayment for Specialist office visits. 
 
You have been asked to pay a $35 copayment for specialist office visit. This item/service falls within the 
Specialist 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 specialist 
office visit provided on July 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for medical eye exam provided on August 23, 
2022. 
 
You asked the Plan to waive the copayment for medical eye exam. You say that you shouldnt have to pay for 
this. 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 $40 
copayment for Medical eye exam. 
 
You have been asked to pay a $40 copayment for medical eye exam. This item/service falls within the Medical 
eye exam 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. You have been asked to pay $38.54 which is less than the standard $40 copayment for medical eye 
exams. Therefore, we decided that the Plan does not have to waive the copayment for medical eye exam 
provided on August 23, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 29, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 procedure code 70450 billed for date of service July 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70480 billed for date of service May 13, 
2022. 
 You asked the Plan to pay for procedure code 70480. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70480 is bundled into payment for 
code 70450. 
 
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 70480 
is a column II code to column I code 70450. 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 procedure code 70480 billed for date of service May 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrical stimulator supplies, 2 lead, per month, (e.g. tens, 
nmes) (procedure code A4595) provided to the enrollee on June 12, 2022. 
 
 
You asked the Plan to pay for the supplies. You say that this should be paid for. The Plan denied your request. 
The Plan says there is evidence of misrepresented services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Medicare rules say that durable medical equipment (DME) supplies must be provided with a proof of delivery. 
 
We find that procedure code A4595 is not supported in the medical record. The required documentation 
pertaining to the proof of delivery of these supplies was not provided. Based on this information, we decided 
that Medicare rules for coverage of the supplies have not been met. Therefore, we decided that the Plan does 
not have to pay for electrical stimulator supplies, 2 lead, per month, (e.g. tens, nmes) (procedure code A4595) 
provided to the enrollee on June 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G2083 billed for date of service July 15, 
2022. 
 
You asked the Plan to pay for procedure code G2083. You say that this was billed correctly for medically 
necessary care. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code G2083 is 1. The MAI value for this code is 2. You billed 84 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code G2083 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code G2083 billed for date of service July 15, 2022.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for emergency room services (procedure code 99285) provided to the 
enrollee on June 16, 2022. 
 
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 that this was denied because it's bundled to another service. 
 
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. The plan has not submitted a valid denial reason for this case. A review of the 
National Correct Coding Initiative (NCCI) edits shows that the plan has reversed the Column 1/Column 2 edit 
pairs in this case. CPT 99285 is the column 1 code to CPT 99283, as CPT 99285 is the more comprehensive 
code with the higher level of care. The plan has denied this stating that CPT 99285 is the column 2 code. 
Therefore, we decided that the Plan has to pay for emergency room services (procedure code 99285) provided 
to the enrollee on June 16, 2022.  
 
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 inpatient psychiatric treatment. 
 
You asked the Plan to pre-approve inpatient psychiatric treatment. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric treatment. Our 
reviewer says that the services are not medically necessary.  Our physician reviewer found based upon review of the records provided the enrollee does not meet criteria for 
acute inpatient mental health treatment as this patient was not shown to be a danger to herself or others. There 
were no auditory or visual hallucinations noted. The enrollee was cooperative and compliant with treatment 
while not showing any aggressive behaviors. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric treatment have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient psychiatric treatment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee walker scooter. 
 
You asked the Plan to pre-approve a knee walker scooter. You say that the item is necessary. The Plan denied 
your request. The Plan says the requested item is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that in the case of equipment categories that have 
been determined by CMS to be covered under the DME benefit, the list outlines the conditions of coverage that 
must be met if payment is to be allowed for the rental or purchase of the DME by a particular patient, or cross-
refers to another section of the manual where the applicable coverage criteria are described in more detail.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a knee walker scooter have not been met. Therefore, we decided that the Plan does not have to pre-
approve a knee walker scooter.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for a continuous glucose monitor (CGM) and related supplies provided on 
December 30, 2021. 
 
You asked the Plan to pay for a CGM and related supplies. You say that the items at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says that rules for payment have not been 
met. 
 
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. Specifically, the Plan has issued a denial due to not meeting the mandated 
timeframe for case processing. The Plan has indicated that they would have approved this request. Therefore, 
we decided that the Plan has to pay for a CGM and related supplies provided on December 30, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the manual wheelchair and accessories provided on March 
21, 2022. 
 
You asked the Plan to pay for the manual wheelchair and accessories. You say that this is medically necessary 
and should be covered. The Plan denied your request. The Plan says no proof of delivery notice signed by the 
enrollee is 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. Therefore, we 
decided that the Plan does not have to pay for the manual wheelchair and accessories provided on March 21, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vivistim. 
 You asked the Plan to pre-approve Vivistim. You say that the health of the enrollee is being compromised. The 
Plan denied your request. The Plan says the clinical value and effectiveness of Vivistim in the setting of 
hemiplegia after a cerebrovascular accident (CVA) have not been demonstrated in the peer-reviewed literature. 
 
The Plan follows Medicare rules. Medicare rules say that VNS is covered for certain indications and when 
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 Vivistim. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the records provided for review did not 
support that the enrollee has a diagnosis of medically refractory partial onset seizures--which is the primary 
indication for which Medicare covers VNS. The enrollee does not have TRD, and he is not participating in a 
clinical trial. The VNS in this case is sought for hemiparesis, a condition for which the NCD does not explicitly 
support its use. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vivistim have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vivistim.