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

 
We decided that the Plan does not have to pre-approve home infusion therapy, catheter care/maintenance, 
implanted access device (S5502), home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 
24 hours (S9500), and home infusion/specialty drug administration, per visit (up to 2 hours) (99601). 
 
You asked the Plan to pre-approve procedure codes 99601, S9500, S5502. You say that the services should be 
covered. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure codes 99601, S9500, S5502 have a Status Indicator of I on the Physician Fee Schedule. 
This means that procedure codes 99601, S9500, S5502 are not valid for Medicare purposes. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 99601, S9500, S5502 have not 
been met. Therefore, we decided that the Plan does not have to pre-approve home infusion therapy, catheter 
care/maintenance, implanted access device (S5502), home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 24 hours (S9500), and home infusion/specialty drug administration, per visit (up to 2 
hours) (99601).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant/abutment supported removable denture for 
edentulous arch. 
 
You asked the Plan to pre-approve the dental services. You say that you cannot eat properly and need this 
service approved. The Plan denied your request. The Plan says this service is not a covered benefit under your 
dental plan. 
 
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 an 
implant/abutment supported removable denture for edentulous arch.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99252 billed for date of service September 9, 
2022. 
 
You asked the Plan to pay for procedure code 99252. You say that this is the standard of care. The Plan denied 
your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99252 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99252 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99252 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99252 billed for date of service September 9, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service August 4, 
2022. 
 
You asked the Plan to pay for the billed services. You say that providers render treatment when needed. The 
Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file shows that the services at issue were reimbursed by the Plan 
on August 26, 2022. A comparison of the two claims shows these are exact duplicates. There is no evidence 
presented to support that the billed services were provided twice on the same date.  Based on this information, we decided that the Medicare rules for the billed services have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99285 billed for date of service 
August 4, 2022.
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 this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the request is not medically necessary, when the enrollee 
is ready to leave the hospital, they can safely receive this care in another setting, such as a Skilled Nursing 
Facility (SNF). 
 
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 the requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
 
 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve personal care assistant services. 
 
You asked the Plan to pre-approve personal care assistant services. You say that a personal care assistant is 
medically necessary for the enrollee. The Plan denied your request. The Plan says a personal care assistant is 
not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of personal care assistant services have not been met. Specifically, we find that the services at issue in 
this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve 
personal care assistant services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve the use of Cogenex amniotic membrane (Q4229). 
 
You asked the Plan to pre-approve Cogenex amniotic membrane. You say that the requested services are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says that the requested services are 
experimental/investigational. 
 
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 Cogenex amniotic membrane. Our 
reviewer says that the requested services are considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee has undergone multiple conservative treatments, including bone 
debridement, tissue transfer, offloading, surgical shoe, immobilizing boot, wound care and dressings. 
Unfortunately, the enrollee's wound would not heal. Application of skin substitutes such as Cogenex is noted in 
the literature and in several studies to expedite healing and closure of non-healing diabetic wounds. These 
applications are utilized in wounds that have stalled and have stopped responding to standard wound 
debridement and offloading. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Cogenex amniotic membrane have been met. Therefore, we decided that the 
Plan has to pre-approve the use of Cogenex amniotic membrane (Q4229).  
 
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 pre-approve Freestyle lite test strips. 
 
You asked the Plan to pre-approve Freestyle lite test strips. You say that you are requesting Freestyle lite test 
strips for the enrollee. The Plan denied your request. The Plan says only the preferred brand products listed in 
the EOC are covered. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for test strips. Therefore, we decided that the Plan does not have to pre-approve Freestyle lite test strips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for dates of service March 22, 
2022, to March 24, 2022. 
 
You asked the Plan to pay for the billed services. You say that the medical records support the claim. The Plan 
denied your request. The Plan says the code is not supported in the records. 
 
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 99233 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high 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 
unstable or has developed a significant complication or a significant new problem. Typically, 35 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 
was admitted to the hospital with an exacerbation of chronic obstructive pulmonary disease (COPD). For the 
dates in question, code 99233 was not supported. This evaluation and management code requires two out of 
these three key components: a detailed interval history, a detailed examination and medical decision making of 
high complexity. However, the medical records submitted did not support a detailed interval history and 
medical decision making of high complexity. 
 
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 99233 billed for dates of service March 22, 2022, to March 24, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services provided on June 6, 2021. 
 
You asked the Plan to pay for the emergency room services. You say that the services should be covered. The 
Plan denied your request. The Plan says this claim was files untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the emergency room services was not filed until November 8, 2022. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for the emergency room services provided on June 6, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xipere. 
 
You asked the Plan to pre-approve Xipere. You say that Xipere is medically necessary. The Plan denied your 
request. The Plan says a trial of Triesence is required before alternatives can be considered. 
 
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 Xipere. Our reviewer says that Xipere 
is not medically necessary. Our physician reviewer found the records show no trial of the plan preferred drug, 
or any reason it would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Xipere have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Xipere.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99226 billed for date of service April 5, 
2022. 
 
You asked the Plan to pay for procedure code 99226. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 99226 is bundled into 
payment for code 99223. 
 
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 99226 
is a column II code to column I code 99223 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 99226 billed for date of service April 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary for the 
enrollee to receive ventilator weaning and to return home with family. The Plan denied your request. The Plan 
says the enrollee is receiving the care needed in the hospital where they are now. There is no need to transfer to 
the LTACH at this time. 
 
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 there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where they are currently 
receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve multiple extractions and tori excision. 
 
You asked the Plan to pre-approve the dental services. You say that these services are medically necessary in 
order to prevent worsening infection. The Plan denied your request. The Plan says the requested services are 
non-covered with Original Medicare. 
 
The Plan must follow Medicare rules. Medicare coverage of the requested items or services are not among 
those covered under the medical benefit. Therefore, we decided that the Plan does not have to pre-approve 
multiple extractions and tori excision.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the ventilator is medically necessary for the 
enrollee, and you are requesting reconsideration. The Plan denied your request. The Plan says records do not 
show the results of a laboratory test that measures the oxygen and carbon dioxide in the enrollees arterial 
blood or the results of a test measuring your oxygen at night that meet the criteria above. In addition, 
documentation of a trial and failure of a BiPAP machine is required, due to the order for VAPS settings only. 
The request is not medically 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 service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic respiratory failure consequent to chronic obstructive pulmonary disease and obesity hypoventilation 
syndrome. Provided records document that the home ventilator is being requested for use in average volume 
assured pressure support (AVAPS) mode with auto-titration (AE) which could be provided by a BiPAP device 
with AVAPS and a back-up rate. Provided records do not show trial and failure of a BiPAP device with 
AVAPS and a back-up rate. As stated in the Local Coverage Determination (L33800): "Claims for ventilators 
used to provide CPAP or bi-level CPAP therapy for conditions described in this RAD policy will be denied as 
not reasonable and 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home massage therapy visits. 
 
You asked the Plan to pre-approve the home massage therapy visits. You say that the service is medically 
necessary. The Plan denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve the home massage therapy visits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a myocardial perfusion imaging, tomographic (SPECT) 
(78452). 
 
You asked the Plan to pre-approve a myocardial perfusion imaging. You say that you disagree with the denial. 
The Plan denied your request. The Plan says the enrollee's medical record must document the medical necessity 
of services performed for each date of service submitted on a claim, and documentation must be available on 
request. 
 
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. The records show that medical records were requested by the Plan 
and records were not received. Based on this information, we decided that there is insufficient information in 
the record to determine if Medicare rules for coverage of a myocardial perfusion imaging have been met. . 
Therefore, we decided that the Plan does not have to pre-approve a myocardial perfusion imaging, tomographic 
(SPECT) (78452).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the power mobility device provided on September 11, 2022. 
 
You asked the Plan to pay for the mobility device. The Plan denied your request. The Plan says the 
documentation does not meet the criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
A review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. There are insufficient medical records to show that the provided power mobility device was ordered 
by your treating physician. There are not enough medical records to show that the coverage criteria for a power 
mobility device was medically reasonable or necessary. Therefore, we decided that the Plan does not have to 
pay for the power mobility device provided on September 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hospital bed, total electric, with any type of side rails, 
with mattress (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that your bed is very old. You say that 
it hurts your caregiver's back when trying to crank it. You say that the side railing is coming off. You also say 
that this is hazardous as you toss and turn in your sleep. The Plan denied your request. The Plan says a total 
electric hospital bed is not covered. 
 
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 hospital bed, total 
electric, with any type of side rails, with mattress (E0265).