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

 
We decided that the Plan does not have to pay for the polymerase chain reaction (PCR) nail panel testing 
(87801, 87798, 87481) provided on February 24, 2022. 
 
You asked the Plan to pay for the PCR nail panel. You say that the PCR panel was medically necessary. The 
Plan denied your request. The Plan says a review of the medical literature and clinical practice guidelines do 
not support PCR testing as a first line approach for evaluation of onychomycosis, and it is not widely accepted 
as standard of care. 
 
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 PCR nail panel. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that PCR testing for a mycotic toenail is not standard of care. Standard of care investigation of 
a suspected mycotic toenail includes potassium hydroxide (KOH) and fungal culture. Both of these simple and 
straightforward lab tests are sensitive and can be specific, especially fungal culture. Therefore, the requested 
PCR nail panel testing for this enrollees toenail 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 the PCR nail panel have not been met. Therefore, we decided that the Plan does 
not have to pay for the polymerase chain reaction (PCR) nail panel testing (87801, 87798, 87481) provided on 
February 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns on tooth #4 and 6 (D6740) and a pontic 
on tooth #5 (D6245). 
 
You asked the Plan to pre-approve the crowns and a pontic. You say that you do not understand why none of 
the procedure would be covered. The Plan denied your request. The Plan says that retainer crowns (D6740) and 
a pontic (D6245) are not covered by your dental 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. 
 
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 
retainer crowns on tooth #4 and 6 (D6740) and a pontic on tooth #5 (D6245).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device (33289). 
 
You asked the Plan to pre-approve the device. You say that the device is medically necessary. The Plan denied 
your request. The Plan says there remains a dearth of randomized, blinded clinical studies examining the long-
term clinical outcomes to establish the value of CardioMEMS in patient management. 
 
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 device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this patients clinical 
management. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the CardioMEMS device (33289).
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 the enrollee has dementia and modestly reduced functional status. The enrollee does 
not require and cannot tolerate intensive rehabilitation. The enrollee does not require frequent physiatry 
oversight. 
 
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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for dental services provided on September 2, 2022. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says that the services provided have been processed correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has failed to provide a 2022 Evidence of Coverage. Therefore, we 
decided that the Plan has to pay for dental services provided on September 2, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Libre 14 Day Sensor (A4239). 
 
You asked the Plan to pre-approve the CGM. You say that the CGM is medically necessary. The Plan denied 
your request. The Plan says the Medicare rules have not been met. 
 
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 enrollee is not administering insulin three or more times per day 
and the enrollee is not using a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump. Based 
on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Freestyle Libre 14 Day Sensor (A4239).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services, billed with code 99153, 
provided on October 19, 2021. 
 
You asked the Plan to pay for the billed services. You say that the enrollee had multiple exams on this date of 
service. The Plan denied your request. The Plan says code 99153 is not payable in the facility setting. 
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the moderate sedation services, billed with code 99153, provided on October 19, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve transcatheter placement of intravascular stent(s), cervical carotid 
artery, open or percutaneous, including angioplasty, when performed, and radiological supervision and 
interpretation; with distal embolic protection (37215). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says that the service is not 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 service. Our physician reviewer 
found the documentation supports the medical necessity of the treatment in question. The enrollee is high-risk 
for carotid endarterectomy both from a cardiac standpoint, as well as due to the anatomic location of the carotid 
lesion. The enrollee has both duplex and angiographic confirmation of critical, greater than 80% stenosis of the 
right carotid artery. The proposed procedure is both reasonable and medically necessary and meets coverage 
criteria. 
 
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 service have been met. Therefore, we decided that the Plan has to pre-
approve transcatheter placement of intravascular stent(s), cervical carotid artery, open or percutaneous, 
including angioplasty, when performed, and radiological supervision and interpretation; with distal embolic 
protection (37215).  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two home health skilled nursing visits. 
 You asked the Plan to pre-approve home health services. You say that the enrollee would benefit from 
additional skilled nursing services. The Plan denied your request. The Plan says the 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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
provided records do not document any acute or unstable medical conditions or changes in medication or 
treatment which would necessitate any further skilled nursing visits beyond what have already been approved. 
The records document the enrollee/caregiver has been or will be educated on the enrollee's disease process and 
medications with the nursing visits that have been approved. No medical notes from the enrollee's treating 
physician are provided documenting an order or need for additional skilled nursing services beyond what have 
been approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve two home health skilled nursing visits.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance supplies (A0382) provided on July 22, 2022. 
 
You asked the Plan to pay for the ambulance supplies. You say that you would like this claim processed for 
payment. The Plan denied your request. The Plan says ambulance supplies is not a covered benefit 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance supplies are considered part of the 
general ambulance service and payment for them is included in the payment rate for the transport. Therefore, 
we decided that the Plan does not have to pay for the ambulance supplies (A0382) provided on July 22, 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 the LTACH services are necessary 
because you are at risk for aspiration, your cognition has worsened, and you feel you should have further 
cognitive/neurologic workups done. You also say working with Chinese speaking nurses and therapists may 
enable you to participate more in your treatments. The Plan denied your request. The Plan says the requested 
LTACH services are 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 based on the documentation provided, the Plans denial of ongoing LTACH coverage should be upheld. You have been decannulated. You continue to be physically debilitated youre your 
multiple strokes. You no longer require the level of care provided at an LTACH. You can then be 
transferred/discharged to a lower level of care for any ongoing long term care needs. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the six extractions (D7210) provided on 
June 27, 2022. 
 
You asked the Plan to waive the copayment for the dental services. You say that your provider did not inform 
of the charges prior to the services. 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 $194 
copayment for D7210 extractions.  
 
You have been asked to pay a $194 copayment for six extractions for a total of $1,164. This item/service falls 
within the Dental Services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. 
 
 
  
Therefore, we decided that the Plan does not have to waive the copayment for the six extractions (D7210) 
provided on June 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigationper quadrant (D4921 x2), and 
periodontal scaling and root planing - one to three teeth per quadrant (D4342 x2) provided on October 25, 
2022. 
 
You asked the Plan to pay for the gingival irrigationper quadrant (D4921 x2), and periodontal scaling and 
root planing - one to three teeth per quadrant (D4342 x2).       The Plan denied your request. The Plan says 
these services are not covered under the benefit package. 
 
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 pay for gingival 
irrigationper quadrant (D4921 x2), and periodontal scaling and root planing - one to three teeth per quadrant 
(D4342 x2) provided on October 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for repair, complex, eyelids, nose, ears and/or lips; 2.6 cm to 7.5 
cm provided to the enrollee on June 29, 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 denied code 13152 remains not supported, as there is a more appropriate code to use. 
 
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 13152 is "Repair, complex, eyelids, nose, ears and/or 
lips; 2.6 cm to 7.5 cm." 
 
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 a repair, complex, eyelids, nose, ears and/or lips; 2.6 cm 
to 7.5 cm was performed on June 29, 2022, therefore this 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 repair, complex, eyelids, nose, ears and/or lips; 2.6 cm to 7.5 cm provided to the enrollee on 
June 29, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound (76981) provided on August 10, 2022. 
 
You asked the Plan to pay for the ultrasound. You say that this diagnosis code is valid, and this service should 
be paid. The Plan denied your request. The Plan says the principal diagnosis code used on this claim is not an 
appropriate diagnosis code and must be resubmitted with the etiology code first. 
 
The Plan must follow Medicare rules. Medicare rules say that certain conditions have both an underlying 
etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD-
10-CM follows a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation. Manifestation only codes have a "code first" note.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare billing rules 
have not been met. Specifically, this claim was billed with code K74.00 (hepatic fibrosis, unspecified) as the 
primary and only diagnosis. However, codes within the K74.0 code group have a code first note, indicating 
that these codes must be coded after the underlying liver disease. It is not appropriate to use codes with a code 
first note as a primary diagnosis. Therefore, we decided that the Plan does not have to pay for the ultrasound 
(76981) provided on August 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service February 12, 
2022, and procedure code 99239 billed for date of service February 28, 2022. 
 
You asked the Plan to pay for procedure codes 99223 and 99239. You say that these services were necessary 
and were reported correctly. The Plan denied your request. The Plan says these services are not supported as 
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. 
 
 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 codes 99223 and 99239. Our reviewer says that 
the submitted records do not contain the required data elements to report the codes in question. Our reviewer 
found that the documentation for February 12, 2022, does not contain a comprehensive past, family and/or 
social history (PFSH). This data element is required to support code 99223. In addition, the documentation for 
February 28, 2022, does not state how much time was spent performing discharge day management. Since this 
is a time-based code, this data element is required to report 99239. 
 
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 codes 99223 and 99239 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code 99223 billed for date of service February 12, 2022, and 
procedure code 99239 billed for date of service February 28, 2022.