Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment of root canal obstruction (D3331) and pulpal 
debridement (D3221). 
 
You asked the Plan to pre-approve root canal services. You say that these services are necessary. The Plan 
denied your request. The Plan says these services are not covered by your dental benefit. 
 
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 
treatment of root canal obstruction (D3331) and pulpal debridement (D3221).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy visits to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve physical therapy visits. You say that you are requesting this specific 
physical therapy facility because they facility is located where you currently reside. You say that you are 
unable to drive due to a medical diagnosis regarding your vision. The Plan denied your request. The Plan says 
there are equally qualified providers in-network capable of performing services requested. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy visits to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on February 15, 2022, to 
February 20, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that these 
services were medically necessary and are supported in the record. The Plan denied your request. The Plan says 
DRG 871 is not appropriate as the diagnosis of sepsis, unspecified organism (A41.9) is not supported in the 
medical record. The Plan argues that DRG 194 is more appropriate in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with sepsis, unspecified organism (A41.9). 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 inpatient hospital services at the DRG originally billed. 
Our reviewer says that this diagnosis is not supported in the medical record for this inpatient admission. Our 
physician reviewer found that the enrollee presented to the facilitys emergency department with the chief 
complaint of generalized fatigue and malaise. The review of systems was non-specific beyond malaise and 
chest pain, and the provider documented that the enrollee had a normal appearance, no acute distress, no 
respiratory distress and normal pulmonary effort. The enrollee was diagnosed with pneumonia. Multiple organ 
dysfunction syndrome (MODS) is characterized by progressive organ dysfunction in a severely ill patient, with 
failure to maintain homeostasis without intervention. It is the end stage in infectious conditions and 
noninfectious conditions. In this case there was no clinical or laboratory evidence of sepsis. The review has 
determined that the medical records did not support the billing of sepsis, unspecified organism (A41.9).  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on February 15, 2022, to February 20, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs continued critical care 
recovery and daily physician oversight. The Plan denied your request. The Plan says the request is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walker with seat. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a walker is covered when specific 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records do not support that you are 
not able to perform mobility-related activities of daily living (MRADLs). You do not have a mobility 
impairment that will be corrected by the walker. The walker is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a walker with seat.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs rehabilitation to get better and 
progress. The Plan denied your request. The Plan says based on Medicare guidelines, the requested IRF 
services do not meet the requirements for approval. 
 
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 complexity of the enrollees nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for wrist brace provided on January 24, 2022. 
 
You asked the Plan to waive the coinsurance for wrist brace. You say that the brace was useless. 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 20% 
coinsurance for prosthetic devices and related supplies. The allowed amount of this wrist brace total $44.26, 
resulting in a coinsurance amount $8.85. 
 
You have been asked to pay 20% coinsurance for wrist brace. This item/service falls within the prosthetic 
devices and related supplies 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 coinsurance for wrist brace 
provided on January 24, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapy services provided from August 2, 2021, to 
August 31, 2021. 
 
You asked the Plan to pay for the therapy services. The Plan denied your request. The Plan says the billed 
codes are not supported. 
 
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. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the therapy services have been met. 
The submitted documentation does not contain medical records from the non-contract provider. Therefore, we 
decided that the Plan does not have to pay for the therapy services provided from August 2, 2021, to August 31, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Libre 14-day reader device (K0554). 
 
You asked the Plan to pre-approve the Freestyle Libre. You say that you want to appeal the denial because you 
have diabetes, and this device is easy for you to use. The Plan denied your request. The Plan says the enrollee 
is not insulin treated and does not meet the Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the Freestyle Libre have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the Freestyle Libre 14-day reader device (K0554).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CT scan, abdomen and pelvis; without contrast material 
(CPT code 74176-26) provided on November 3, 2021. 
 
You asked the Plan to pay for the CT scan. You say that the claim should be paid. The Plan denied your 
request. The Plan says the records submitted do not indicate that two separate services were 
performed/supported. 
 
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 CT scan have not been met. The records submitted do not 
indicate that two separate services were performed/supported. Two radiology reports were submitted which are 
exact duplicates of each other. These reports were signed at exactly the same time (Eastern time vs Pacific 
time, 3 hour time difference), by the same provider, with the exact same accession numbers and results. These 
reports are exact duplicates. Therefore, coding guidelines have not been met and the denial remains upheld. 
This is an administrative coding decision and not based upon medical necessity. Therefore, we decided that the 
Plan does not have to pay for CT scan, abdomen and pelvis; without contrast material (CPT code 74176-26) 
provided on November 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a backup battery for a continuous positive airway 
pressure (CPAP) device. 
 
You asked the Plan to pre-approve a backup battery. You say that the requested item is a necessity because you 
are without electricity. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve a backup battery for a continuous positive airway pressure 
(CPAP) device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vascepa. 
 
You asked the Plan to pre-approve Vascepa. You say that the enrollee has tried Livalo, Simvastatin, and Zetia, 
all of which they were intolerant to. You also say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested drug is considered self-administered. The 
Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also 
says the requested drug is not covered under Medicare Part B. 
 
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 Vascepa.  
 Benefits for Vascepa 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound guidance for vascular access requiring 
ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime 
ultrasound visualization of vascular needle entry, with permanent recording and reporting (CPT code 76937) 
provided on March 5, 2022. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is 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 service have not been met. As the CPT code 76937 was billed 
without an appropriate primary code and not performed by the same practitioner on the same date of service; 
we find that Medicare rule for payment for CPT codes 76937 has not been met. Therefore, we decided that the 
Plan does not have to pay for the ultrasound guidance for vascular access requiring ultrasound evaluation of 
potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of 
vascular needle entry, with permanent recording and reporting (CPT code 76937) provided on March 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Iovera pain system. 
 
You asked the Plan to pre-approve the requested services. You say that you are in pain. The Plan denied your 
request. The Plan says there is not enough medical literature to support the use. 
 
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 the requested services. Our physician 
reviewer found that you have a history of chronic left knee pain. The requested Iovera procedure/system is 
considered experimental and investigational. Based on review of abstracts of peer-reviewed literature, there is 
insufficient evidence to inform conclusions regarding the Iovera system. The documentation does not support 
that the Iovera treatment is safe and effective. The documentation does not support that Iovera treatment is 
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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Iovera pain system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided on May 
20, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the claim should be paid. The 
Plan denied your request. The Plan says Medicare rules say that CMS does not pay any provider or supplier 
other than the facility or hospital for services furnished to the beneficiary. The Plan states the facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements 
made between the facility and hospital and outside providers. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Furthermore, the enrollee used the equipment in the 
facility during or after surgery. Payment for this service would have been included under the facility claim. 
Payment for this service is the responsibility of the facility or hospital that provided the surgery. Therefore, we 
decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided on May 20, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from December 14, 2021 
to December 19, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 
  You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
would like the denied DRG to be approved for immediate payment. The Plan denied your request. The Plan 
says the determination to remove principal diagnosis code N17.9 is upheld. The Plan also says payment of 
DRG 682 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code, N17.9, defined as Acute 
kidney failure, unspecified. 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 inpatient 
hospital services at the DRG originally billed. Our reviewer says that the submitted DRG is not supported. Our 
physician reviewer found the enrollee's initial creatinine of 1.28 improved to 1.08 with hydration. Optimal 
hydration should be achieved before determining a diagnosis of AKI, since dehydration may cause transient 
elevation of serum creatinine. Our reviewer found that the medical records did not support the billing of Acute 
kidney failure, unspecified with DRG 682. The medical records do not support the billing of original DRG 682. 
Our physician reviewer also found that the revised DRG 689 is more appropriate.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided from December 14, 2021 to December 19, 2021, at the Diagnosis 
Related Group (DRG) originally billed.