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

 
We decided that the Plan does not have to pay for a guided tissue regeneration (D4266), and an extraction 
(D7140), and a bone replacement graft (D7953) provided by an out-of-network provider on October 25, 2021. 
 
You asked the Plan to pay for a guided tissue regeneration and an extraction (D7140), and a bone replacement 
graft. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the 
maximum allowance amount of $1,000 has already been met. 
 
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.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a guided tissue regeneration and an extraction (D7140), and a bone replacement graft have not 
been met. Therefore, we decided that the Plan does not have to pay for a guided tissue regeneration (D4266), and an extraction (D7140), and a bone replacement graft (D7953) provided by an out-of-network provider on 
October 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
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 step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has postmenopausal 
osteoporosis. There are no records showing that she has tried and failed the Plan's required drugs, an oral 
bisphosphonate and zoledronic acid, or that the required drugs would be contraindicated or less effective. Prolia 
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 Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99203) and manual therapy 
techniques (97140) provided September 30, 2021 to October 14, 2021. 
 
You asked the Plan to pay for the chiropractic services. You say that you believe this treatment is covered by 
your Plan. The Plan denied your request. The Plan says this service is not covered when rendered by a 
chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the outpatient office visit (99203) and manual therapy techniques (97140) 
provided September 30, 2021 to October 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) 
joint. 
 
You asked the Plan to pre-approve RFA of the SI joint. You say that this procedure is medically necessary for 
your condition. The Plan denied your request. The Plan says the requested procedure is 
experimental/investigational. 
 
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 RFA of the SI joint. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested procedure is considered an experimental/investigational approach 
because of the wide variation in efficacy reported in the peer reviewed literature. Therefore, the request is 
deemed 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 RFA of the SI joint have not been met. Therefore, we decided that the Plan does 
not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for treatment with Propofol provided on July 27, 2021. 
 
You asked the Plan to pay for Propofol. You say that the treatment at issue was a medical necessity for the 
enrollee. The Plan denied your request. The Plan says that rules for payment have not been met. 
 
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. Specifically, the case record does not include documentation of the submitted 
claim. It is the responsibility of the Plan to substantiate its denial rationale. In this case, the Plan has not 
fulfilled that responsibility so we must find in your favor. Therefore, we decided that the Plan has to pay for 
treatment with Propofol provided on July 27, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from September 
22, 2021, to September 23, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the inpatient care was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found based on the provided documentation, the enrollee did not appear to have complex 
disease or any evidence of ACS or other acute condition that would require prolonged workup and treatment in 
the hospital. It was not expected that the enrollee would require hospital services that would likely cross 2 
midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from September 22, 2021, to September 
23, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a duplex scan provided to the enrollee on August 28, 2021. 
 
You asked the Plan to pay for the scan. You say that this should be paid for. The Plan denied your request. The 
Plan says the diagnosis code associated to it is mismatched to the procedure modifiers on the claim. 
 
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 93971 is "Duplex scan of extremity veins including 
responses to compression and other maneuvers; unilateral or limited study." 
 
We find that CPT code 93971 is not supported in the medical record. Specifically, the modifier used in this 
case - LT - specifies that the scan was on the left side. However, the diagnosis code - I82.409 - Acute embolism 
and thrombosis of unspecified deep veins of unspecified lower extremity - has unspecified laterality. A more 
specific diagnosis code would be needed here. Based on this information, we decided that Medicare rules for 
coverage of the scan have not been met. Therefore, we decided that the Plan does not have to pay for a duplex 
scan provided to the enrollee on August 28, 2021.
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 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. 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 medically necessary. Our physician reviewer found the enrollee was 
admitted to the hospital with pneumonia from a COVID-19 infection and developed respiratory failure. He 
requires ongoing acute care that is not being denied at the current facility. The medical record does not indicate 
that the enrollee requires services that he is not currently receiving but that would be available at the LTACH 
facility. The LTACH services are 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 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a metabolic positron emission tomography (PET) scan 
for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says this request cannot be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
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 scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found the case file does not 
support that the enrollee has a recent diagnosis of dementia, with cognitive decline of six months. The 
documentation does not support that the enrollee meets diagnostic criteria for both Alzheimers disease (AD) 
and fronto-temporal dementia (FTD), and that FDG PET imaging is reasonably expected to help clarify the 
diagnosis between FTD and AD and help guide future treatment. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a metabolic positron emission tomography (PET) scan for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia for the enrollee. 
 
You asked the Plan to pre-approve Prolia. You say that this is medically necessary for the patients treatment 
for age-related osteoporosis. The Plan denied your request. The Plan says that the member has not tried and 
failed zoledronic acid. 
 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 Prolia. Our reviewer says that Prolia is 
not medically reasonable and necessary for the enrollee. The Plan requires a history of osteoporosis-related 
fracture or that the enrollee has tried or cannot use zoledronic acid before they will approve Prolia. In this case, 
the patient has not tried and failed the required drug. There is no documentation provided indicating that the 
Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. Our 
physician reviewer found that the enrollee's condition does not meet step therapy criteria for Prolia. 
 
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 Prolia for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the discharge day management (99239) provided on January 
10, 2021. 
 
You asked the Plan to pay for the evaluation and management service. You say that the provider has not 
received payment. The Plan denied your request. The Plan says this claim was previously processed and paid. 
 The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be an exact duplicate are rejected and do not have appeal rights.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the evaluation and management service have not been met. The record shows that the Plan has 
processed and paid this service to the same provider on the same date of service. Therefore, we decided that the 
Plan does not have to pay for the discharge day management (99239) provided on January 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 24, 2021. 
 
You asked the Plan to pay for the lab services. You say that you provided these services in good faith and they 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on June 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visit services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve office visit services. You say that these services are medically reasonable 
and necessary. The Plan denied your request. The Plan says they have in-network providers available for the 
enrollee's medical needs. 
 
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 
office visit services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E1226, 
K0195, E0990, E2211, E2201) for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is not medically necessary. The Plan denied 
your request. The Plan says this is medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found in terms of E1226, the documentation does not reveal that this enrollee is at high risk of pressure ulcer or 
uses intermittent catheterization. The K0195 was requested to reduce swelling in distal legs and reduce 
contractures. The documentation does not reveal significant bilateral lower extremity edema. The enrollee does 
not meet the criteria for a reclining back on a wheelchair. The documentation does not reveal that the enrollee 
is unable to flex the knee at ninety degrees. The request for E0990 and K0195 are duplicative and are not 
medically necessary. The approved wheelchair comes with standard foam tires; therefore, these items (E2211, 
E2213) exceed the enrollee's medical needs. E2201 is not medically necessary, as the enrollee's hip width is 18 
inches, therefore the 20 inch seat width is not appropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional power wheelchair accessories (E1226, K0195, E0990, E2211, E2201) for the 
enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the inpatient hospital care provided 
from October 31, 2020, to November 1, 2020. 
 You asked the Plan to pay an additional amount for the inpatient care. You say that the billed diagnosis code is 
supported. The Plan denied your request. The Plan says the billing of diagnosis code A41.9 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, A41.9, sepsis, unspecified 
organism. 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 an additional amount for the inpatient 
care. Our reviewer says that the principal diagnosis code, A41.9, sepsis, unspecified organism, has not been 
supported. Our physician reviewer found while the enrollee's presentation warranted consideration of sepsis as 
a diagnosis, there was no evidence of life-threatening organ dysfunction due to dysregulated host response to 
an infection, persistent hemodynamic instability or cognitive impairment that would be consistent with multi-
system involvement due to sepsis. Therefore, the reviewer found that the provided documentation does not 
support the billing of principal diagnosis code, A41.9, sepsis, unspecified organism.  
 
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 
an additional amount for the inpatient hospital care provided from October 31, 2020, to November 1, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that records do not show that the enrollee requires continued 
treatments and care that can only be given in a hospital setting. 
 
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. 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 she is currently receiving care. There are no 
services available at the LTACH that the enrollee requires that are not available at the health care setting being 
offered by the health plan. Our physician reviewer found that the enrollee's condition does not meet Medicare 
criteria for LTACH 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 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 for the enrollee.