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

 
We decided that the Plan does not have to pre-approve continuation of inpatient mental health care from 
November 1, 2022, forward. 
 
You asked the Plan to pre-approve inpatient mental health care. You say that the enrollee needs to stay at 
hospital for their medical safety and mental health needs. The Plan denied your request. The Plan says the stay 
is not medically necessary. 
 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 mental health care. Our 
physician reviewer found this enrollee does not meet the criteria for treatment in an acute inpatient mental 
health treatment beyond the date in question of November 1, 2022, forward and could have been treated in a 
lesser restrictive setting as they were not showing any suicidal or homicidal ideation, auditory or visual 
hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant 
while not showing any acute threats to safety. 
 
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 mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continuation of inpatient mental health care from November 1, 2022, 
forward.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight additional home care visits. 
 You asked the Plan to pre-approve eight additional home care visits. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 eight additional home care visits. Our 
reviewer says that the documentation does not support that the requested services are medically reasonable or 
necessary. Our physician reviewer found the enrollee is reportedly receiving wound care for a chronic sacral 
wound. The wound care is to be provided two to three times per week. Despite over 100 prior visits, there is no 
clear evidence that this wound is healing. There is evidence that a friend is available to help with wound care 
on an as needed basis. There is no evidence of a change in the treatment plan or wound status, warranting two 
or three weekly home nurse services. Therefore, the enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of eight additional home care visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve eight additional home care visits.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 15740 provided on August 20, 2021. 
 
You asked the Plan to pay for procedure code 15740. You say that the medical records support the billing of 
code 15740. The Plan denied your request. The Plan says that the medical records do not support the billing of 
code 15740. 
 
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 15740 is Flap; island pedicle requiring identification and dissection of an anatomically named axial 
vessel. 
 
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 code 15740. Our reviewer says that the medical 
records support the billing of code 15740 with the description of procedure on page 2 of the operative report. 
 
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 code 15740 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 15740 provided on August 20, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the requested drug is prescribed for an off-label and not 
medically accepted use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Prolia. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
enrollee has a diagnosis of multiple myeloma in remission. The FDA has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a 
supportive citation for the use of the requested drug in the enrollee's clinical situation. No literature from 
Medicare-approved cancer journals was submitted for review. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Prolia (J0897).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an enhanced graphic display (K0108) and an egg switch 
mount (K0108). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that you need the graphic display as you 
are not able to move your arms and legs for maneuvering. You are asking that all accessories be covered so that 
you can continue to better your quality of life and complete activities of daily living with ease. The Plan denied 
your request. The Plan says the requested items are already included with the approved expandable controller 
and should not be requested separately. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  The file shows that you were approved for an expandable controller. Medicare rules show that the requested 
items are already included in the expandable controller. You should not request them separately. Therefore, we 
decided that the Plan does not have to pre-approve an enhanced graphic display (K0108) and an egg switch 
mount (K0108).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Mohs micrographic technique (CPT code(s): 17311 and 
17312) provided on April 19, 2022. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not covered as billed. 
 
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 the services have not been met. CPT code 17311 and 17312 and 
pathology services CPT code 88305 must be reported by a single physician who performs both the surgery and 
pathologic examination of the specimen. A review of the enrollees claim history shows services were 
performed by different providers. Therefore, we decided that the Plan does not have to pay for Mohs 
micrographic technique (CPT code(s): 17311 and 17312) provided on April 19, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six additional physical therapy (PT) visits (beyond the 6 
approved visits). 
 
You asked the Plan to pre-approve the additional PT visits. You say that it is felt that the requested number of 
visits are required. The Plan denied your request. The Plan says six visits will be sufficient to establish the 
home exercise program. Further skilled therapy is not required beyond that.  
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 PT 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 requested number of PT sessions is not shown to be 
reasonable and necessary. The enrollee continues with some pain. She has persistent fixed arthritis but is able 
to walk household and community distances. She has persistent mild weakness in left lower extremity. She is 
able to do home exercises and current therapy consists of repetitive exercise. Strength training is repetitive 
exercise. She does not require more input aside from establishing the 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 PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve six additional physical therapy (PT) visits (beyond the 6 approved visits).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown on tooth #6 and 12 (D2740). 
 
You asked the Plan to pre-approve crowns. You say that the crowns are medically necessary. The Plan denied 
your request. The Plan says that the x-rays do not show the teeth have decay or loss due to fracture involving 
more than 50% of the biting edge of the tooth or tooth surfaces. 
 
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 crowns 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 crowns. Our reviewer says that the 
coverage criteria has not been met. Our physician reviewer found that the documentation provided does not 
meet the criteria of significant coronal breakdown due to caries or fracture for coverage of crown restorations 
(D2740) for tooth #6 and 12. 
 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 crowns have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a crown on tooth #6 and 12 (D2740).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87150 billed for date of service June 6, 2022. 
 
You asked the Plan to pay for procedure code 87150. You say that these services were necessary and are 
supported as billed. The Plan denied your request. The Plan says they have agreed to pay for the other services 
billed; however, the medical records provided do not support reporting code 87150 separately from the other 
services 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 87150 is culture typing; identification by nucleic acid 
(DNA or RNA) probe, amplified probe technique, per culture or isolate, each organism probed. 
 
 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 code 87150. Our reviewer says that the medical 
records do not support the billing of code 87150 with modifier 59 for separate payment. Our reviewer found 
procedure code 87150 was reported in addition to code 87798. However, the medical record does not include 
enough documentation to confirm if modifier -59 is appropriate in this case to report 87150 as a distinct 
procedural service from 87798, as identification by nucleic acid methodology cannot be verified in the 
laboratory report. 
 
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 code 87150 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87150 billed for date of service June 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power seat elevation (E2300), an expandable controller 
(E2377), an expandable controller harness (E2313) and an electronic accessory (E2311). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that you disagree with the denial. The Plan 
denied your request. The Plan says although there are three requested power options (tilt, recline and elevating 
leg rests), there is not a medical need to control these power options through the joystick. Seat elevation is not a 
covered benefit with the Plan. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 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 wheelchair accessories. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found a group 3 power wheelchair can 
be covered if the medical necessity for a PWC is met and if the disorder causing the mobility limitation is a 
neurological condition, myopathy or congenital skeletal deformity.  You also must require a drive control 
interface, power tilt or a power recline seating system and if there has been a specialty evaluation that was 
performed by a licensed/certified medical professional, such as a physical or occupational therapist. An 
expandable controller is an electronic system that is capable of accommodating one or more additional features 
and can operate 3 or more powered seating options. In this case, you have a neurologic disorder with functional 
deficits. Criteria for a power wheelchair are met. The requested electrical accessories are not medically 
necessary as you do have use of the upper extremity and can operate and control the power options using the 
switches that are included in the basic wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve power seat elevation (E2300), an expandable controller (E2377), an expandable 
controller harness (E2313) and an electronic accessory (E2311).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on March 24, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 22830 is not covered. 
 
The Plan must follow Medicare rules. The rules say that CPT code 22830 shall not be reported with another 
procedure of the spine in the same anatomic area.  
 
We looked at the file and Medicare rules. Procedure code 22830 was billed with approved codes 63042 and 
63044 representing a laminotomy. Code 22830 cannot be billed with another spine procedure in the same area. 
Therefore, we decided that the Plan does not have to pay for the surgical services rendered on March 24, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance oxygen and oxygen supplies, life sustaining 
situation (A0422) provided on May 22, 2022. 
 
You asked the Plan to pay for the ambulance oxygen and oxygen supplies. You say that the services were 
medically necessary. The Plan denied your request. The Plan says medical necessity for the denied oxygen has 
not been established. 
 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 ambulance oxygen and oxygen supplies. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that the notes describe the enrollee as not needing oxygen during 
transport, although it was given anyway. There was no evidence of the enrollee having hypoxia at the time of 
transport. Therefore, based on the provided documentation, this request for oxygen support during ambulance 
transport will be considered 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 ambulance oxygen and oxygen supplies have not been met. Therefore, we 
decided that the Plan does not have to pay for the ambulance oxygen and oxygen supplies, life sustaining 
situation (A0422) provided on May 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic procedures provided on February 16, 2022, to 
April 6, 2022.  
You asked the Plan to pay for therapeutic procedures. You say that the claims were originally denied because 
of incorrect billing. You say upon review of the claims please provide any payment to you, as you have already 
paid the full amount for these services. The Plan denied your request. The Plan says the case was reviewed with 
the limited information and it shows that you received the therapy at an out-of-network dentist's office and your 
diagnosis was not specified. 
 
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. The rules also say that Medicare covers treatment for TMJ syndrome only 
when the condition or symptom is medical in nature. 
 
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 therapeutic procedures. Specifically, 
no medical records or diagnosis information showing that your condition or symptom is medical in nature have 
been submitted. Therefore, we decided that the Plan does not have to pay for therapeutic procedures provided 
on February 16, 2022, to April 6, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy provided by a participating 
provider. 
 
You asked the Plan to pre-approve physical therapy. You say that additional PT is medically necessary. The 
Plan denied your request. The Plan says 16 PT sessions have been approved. 
 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 the enrollee should be able to safely transition to an independent home 
exercise program with the already approved therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage for 8 additional physical therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional physical therapy provided by a participating provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gemtesa 75MG tablet. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Gemtesa is a self-administered drug and does not fall under Medicare Part B 
coverage.  
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Gemtesa 75MG tablet.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services to be provided by an Endodontist. 
 
You asked the Plan to pre-approve dental services to be provided by an Endodontist. You say that you would 
like the Plan to reconsider their denial. The Plan denied your request. The Plan says dental services are only 
covered when provided by a general dentist. 
 
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 when provided by an Endodontist. Therefore, we decided that the Plan 
does not have to pre-approve dental services to be provided by an Endodontist.