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

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0266). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that you cannot walk. You say that it is 
difficult for your caregiver to raise and lower the bed. You also say that an electric bed is medically necessary. 
The Plan denied your request. The Plan says a total electric hospital bed is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0266).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (CPT 99285) provided on 
October 5, 2022. 
 
You asked the Plan to pay for the emergency department visit (CPT 99285). You say that CPT 99285 is 
medically necessary. The Plan denied your request. The Plan says that CPT 99285 is not medically necessary. 
 
The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect 
the services provided.   
 
In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the 
evaluation and management of a patient which requires three components (taking into account the urgency of 
the clinical condition or the patient's mental status): 
 
1. a comprehensive history; 
2. a comprehensive examination; and 
3. medical decision making of high complexity.  
In addition, CPT code 99285 usually includes a presenting medical problem of high severity and immediate 
significant threat to life or physiologic function.  
 
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 pay for the emergency department visit  
(CPT 99285) Our reviewer says that CPT 99285 is not medically necessary. Our reviewer found that the 
enrollee with a history of hypertension (HTN), coronary artery disease (CAD)- status post percutaneous 
coronary intervention (PCI) x 2, sick sinus syndrome (SSS) status post pacemaker, degenerative disc disease 
(DDD), depression, chronic lymphoproliferative disease (LBP), and dyslipidemia who presented to the 
emergency department (ED) October 5, 2022, with left jaw pain. The enrollee was to have a nuclear stress test 
the following day. The enrollee was evaluated with a history and physical exam, laboratory studies and an 
electrocardiogram (EKG). The enrollee was diagnosed with trigeminal neuralgia and started on Tegretol 
therapy. He was discharged with follow-up with otolaryngologist. The review has determined that CPT 99284 
was more appropriate in this case. There was no decision making of high complexity. The presenting problems 
were not of high severity, posing an immediate significant threat to life and physiologic 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 the emergency department visit (CPT 99285) have not been met. Therefore, we 
decided that the Plan does not have to pay for an emergency department visit (CPT 99285) provided on 
October 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis (ko), double upright, thigh and calf, with 
adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or 
without varus/valgus adjustment, prefabricated, off-the-shelf (L1852) and suspension sleeve (L2397). 
 
You asked the Plan to pre-approve a knee orthosis with accessory. You say that the enrollee needs these items. 
The Plan denied your request. The Plan says the requested items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a knee orthosis, with an adjustable flexion and 
extension joint that provides both medial-lateral and rotation control, are covered if the beneficiary has had 
recent injury to or a surgical procedure on the knee(s). 
 
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 knee orthosis with accessory. Our 
reviewer says that the requested knee orthosis is not medically necessary. Our physician reviewer found the 
provided documentation does not indicate that the enrollee has had a recent injury to or a surgical procedure on 
the knee(s). The reviewer found that the enrollee is ambulatory but has no objective knee instability on physical 
examination. Therefore, the reviewer found that the requested orthosis is not medically reasonable or 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 a knee orthosis with accessory have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a knee orthosis (ko), double upright, thigh and calf, with adjustable 
flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without 
varus/valgus adjustment, prefabricated, off-the-shelf (L1852) and suspension sleeve (L2397).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nerve conduction studies; 9-10 studies rendered on October 
19, 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 Current Procedural Terminology (CPT) code 95911-26 (1 unit) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 95911 is "Nerve conduction studies; 9-10 studies." 
 
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 not supported by the medical records. Our reviewer found that the medical records provided 
does not include sufficient documentation to validate that 9-10 studies for nerve conduction studies were 
performed. The procedure cannot be verified. 
 
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 nerve conduction studies; 9-10 studies rendered on October 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (ESI) (62323). 
 
You asked the Plan to pre-approve a repeat ESI. You say that the enrollee needs this injection. The Plan denied 
your request. The Plan says the initial injection did not give the enrollee 50% pain relief for 3 months. The Plan 
also says that there is no indication that an alternative approach will be used. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat ESI may be considered medically reasonable 
and necessary when the medical record documents that the first injection provided at least 50% of sustained 
improvement in pain relief for three months. 
 
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 repeat ESI. Our reviewer says that a 
repeat ESI is not medically necessary. Our physician reviewer found the provided documentation indicates that 
the enrollee previously had an injection which provided 80% relief for about two weeks. Therefore, the 
reviewer found that a repeat ESI is not medically reasonable or 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 a repeat ESI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat epidural steroid injection (ESI) (62323).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve pelvic ultrasound. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that it is difficult to determine medical necessity for a pelvic ultrasound without 
previous imaging results for verification. 
 
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 services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the patient has a history of stage IIa invasive ductal carcinoma of the breast, for which they receive 
chemotherapy. The enrollee has a BRCA-1 mutation. As such, she is at risk for endometrial carcinoma and the 
request for pelvic ultrasound to assess endometrial thickening is routine for this scenario. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve pelvic ultrasound.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT). 
 
You asked the Plan to pre-approve SBRT. You say that this is the chosen method of treatment. The Plan denied 
your request. The Plan says this 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 SBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found SBRT may be medically necessary; however, it is feasible that the positron emission 
tomography/computed tomography (PET/CT) scan can reveal a higher stage of disease or a biopsy could show 
a non-malignant cause. As these records are not provided, it would not be standard of care to offer SBRT 
without PET/CT, to not account for a biopsy if performed, or a rationale for treating in lieu of biopsy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve stereotactic body radiation therapy (SBRT).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care provided from October 21, 2021, to 
November 8, 2021. 
 
You asked the Plan to pay for home health care. You say that you sent the plan of care and order to the 
provider multiples times for signature; however, it took multiple attempts to get it back. The Plan denied your 
request. The Plan says the plan of care and physician order were not signed within the timely limit. 
 
The Plan must follow Medicare rules. Medicare rules say that the plan of care must be signed and submitted 
before the claim for each 30-day period for services is submitted for the final percentage payment.  
 
We looked at the file and Medicare rules. This claim was submitted on December 20, 2021; however, the plan 
of care was not signed until April 27, 2022. Based on this information, we decided that Medicare rules for 
coverage of home health care have not been met. Therefore, we decided that the Plan does not have to pay for 
home health care provided from October 21, 2021, to November 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service March 9, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says there is 
insufficient information to corroborate the services. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 
 We looked at the file and Medicare rules. In this case, medical records were not provided to show that code 
99223 was supported. The file shows that the Plan made several attempts to obtain additional information 
without success. Based on this information, we decided that the Medicare rules for coverage have not been met.  
Therefore, we decided that the Plan does not have to pay for procedure code 99223 billed for date of service 
March 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a periodic oral evaluation (D0120). 
 
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 dental services from an out-of-network 
provider are not covered by your supplemental 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 are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve a periodic 
oral evaluation (D0120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for dates of service July 13, 
2022, to July 17, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the 
documentation does not support the code. 
 
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 99232 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded 
problem focused interval history; An expanded problem focused examination; Medical decision making of 
moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor 
complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit. 
 We asked our physician 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 billed services. Our reviewer found that the enrollee 
had a history of congestive heart failure, atrial fibrillation and recurrent pleural effusions. The enrollee was 
admitted to the hospital from the emergency department. The medical records submitted did not support an 
expanded problem focused interval history and medical decision making of moderate complexity. Therefore, 
the billed services are not supported. 
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 99232 billed for dates of service July 13, 2022, to July 17, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for dialysis services provided from January 2, 
2021, to August 30, 2022.  
 
You asked the Plan to reduce the copayment for dialysis. You say that you agreed to pay only $100 every 
month and cannot afford to pay this money. 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 20% 
coinsurance for outpatient dialysis.  
 
You have been asked to pay a 20% coinsurance for dialysis from January 1, 2021, to August 30, 2022. This 
item/service falls within the services to treat kidney disease 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 reduce the copayment for dialysis services provided from January 2, 2021, to August 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dog. 
 
You asked the Plan to pre-approve dog. You say that the Plan cannot deny this because the law states this is 
still a service animal. The Plan denied your request. The Plan says the record does not show that you meet the 
coverage criteria for special supplemental benefits for the chronically ill (SSBCI) for a service dog. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of dog have been met. Specifically, 
supporting medical records have not been submitted to show that you qualify for special supplemental benefits 
for the chronically ill (SSBCI) or that the dog you have requested coverage for meets the Plans criteria for 
coverage. Therefore, we decided that the Plan does not have to pre-approve a dog.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 11042, 11043, 17250, 99308 rendered from 
September 29, 2022, to October 7, 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 the claim was denied for a lack of medical necessity. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided records in this case document a total of 16 previous wound debridements from 
01/17/2022 through 09/23/2022. The provided records in this case do not document a specific and detailed 
rationale for the need for the extensive number of debridements performed in this case including the 
wound debridements performed on 09/29/2022 and 10/07/2022 and documented evidence of clear benefit from 
the debridements already provided. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 11042, 11043, 17250, 99308 rendered from September 29, 2022, to October 7, 
2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy. You say that you would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says 10 additional physical therapy 
visits are not medically necessary. 
 
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 physical therapy. 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 that you do  not require services from a skilled therapist. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 10 additional physical therapy visits.