Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services (01402) and peripheral nerve block 
services (64450-59) provided on February 22, 2022. 
 
You asked the Plan to pay for codes 01402 and 64450-59. You say that the medical records support the billing 
of codes 01402 and 64450-59. The Plan denied your request. The Plan says the medical records do not support 
the billing of codes 01402 and 64450-59. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. The rules also state that providers may bill services with a -59 modifier if 
the service billed with the modifier indicates a distinct procedural service.  
 
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 codes 01402 and 64450-59. Our reviewer says that the 
medical records do not support the billing of codes 01402 and 64450-59. Our reviewer found the enrollee 
underwent a left total knee arthroplasty on February 22, 2022. The Procedure note dated February 22, 2022, 
documents Anesthesia Block (Adductor Canal Block). The available medical records do not support the billing 
of 120 units of code 01402. The clinical documentation does not support that the nerve block was at the request 
of the surgeon for pain management postoperatively. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 01402 and 64450-59 have not been met. Therefore, we decided that the 
Plan does not have to pay for the anesthesia services (01402) and peripheral nerve block services (64450-59) 
provided on February 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 18, 2021, billed with 
codes 81206, 81235, 81292, 81301, and 81321. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
August 18, 2021, billed with codes 81206, 81235, 81292, 81301, and 81321.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the incisional biopsy of oral tissue (D7825). 
 
You asked the Plan to pay for the dental service. You say that the services that was billed is not what you had 
done. You say that you had a biopsy of your tongue. You say that this required sutures. You also say that you 
feel this is a medical condition and not dental. The Plan denied your request. The Plan says that the service is 
not covered. 
 
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 pay for the dental service. Our reviewer says that the 
requested dental service is considered medically reasonable and necessary in this case. Our physician reviewer 
found the procedure in this case is considered medical in nature as the tongue is not a supported structure of the 
teeth. The reviewer also found that the taking of a biopsy for an unknown lesion on the tongue would be 
considered medically necessary and reasonable. 
 
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 dental service have been met. Therefore, we decided that the Plan has to pay 
for the incisional biopsy of oral tissue (D7825).  
 
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 a Freestyle Libre continuous glucose monitor (CGM) 
sensor and receiver. 
 
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 criteria for coverage are not 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 documentation indicates that the enrollee does not treat with insulin three or more times per day or use an insulin pump. 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 Freestyle Libre continuous glucose monitor (CGM) sensor and receiver.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve robotic assisted nephroureterectomy. 
 
You asked the Plan to pre-approve the requested services. You say that urological cancer operation guided by 
robotic assistance is the standard of care. The Plan denied your request.  
 
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 robotic assistance is considered as included with the primary surgical procedure and is not 
considered a separate procedure. 
 
 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 robotic assisted nephroureterectomy.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from 
February 14, 2022, to March 15, 2022. 
 
You asked the Plan to pay for the SNF care provided from February 17, 2022, to March 15, 2022. You say that 
the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee 
did not receive daily skilled services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care provided from February 17, 
2022, to March 15, 2022. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. 
Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 SNF care provided from February 17, 2022, to March 15, 2022, have not 
been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care 
provided from February 14, 2022, to March 15, 2022.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pre-approve ten additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says that the enrollee is not eligible for an additional ten 
routine transportation trips. 
 
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 Plan has not provided the trip report to our organization in order 
to determine the enrollees eligibility for this request. The Plan has not substantiated their denial; therefore, we 
must find in the enrollees favor. Therefore, we decided that the Plan has to pre-approve ten additional routine 
transportation trips (A0120).  
 
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 home oxygen and a portable oxygen concentrator. 
 
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 there is no valid physician order. 
 
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating 
physician before dispensing any DMEPOS item to a beneficiary. 
 
We looked at the file and Medicare rules. There is no valid physician order for the equipment. 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 home oxygen and a portable oxygen concentrator.
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 would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the member is receiving 
appropriate in-patient acute care and does not require transfer to a 
Long-Term Acute Care Hospital (LTACH). 
 
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 based on the documentation provided, it is my opinion that the health plans denial of 
LTACH coverage should be upheld.  The patient is currently undergoing treatment at an ACH.  The enrollee 
was intubated/ventilated, subsequently received a tracheotomy and has since been weaned from the ventilator.  
There is no evidence that the enrollee requires services that are not currently available.  As LTACHs and ACHs 
are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.  
The enrollee can remain at the current ACH until such time no acute services are required.  The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC 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 long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the left knee for presurgical 
planning. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says that this service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 this service. Our reviewer says that the 
requested service is medically necessary. Our physician reviewer found that if the MAKO robotic assisted 
surgery is the approved technique for this enrollee's left total knee replacement, then the requested CT scan of 
the left knee is necessary in order to utilize the software of the robotic assisted device. Thus, the CT scan is 
medically necessary if this device is to be used at surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have been met. Therefore, we decided that the Plan has to pre-
approve a computed tomography (CT) scan of the left knee for presurgical planning.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve methadone. 
 
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 self-administered drugs are not covered. 
 
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 methadone.  
 
Benefits for these services 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: 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 IRF care is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says the rules for IRF care have not been met. 
 
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 enrollee is medically stable and does not need a physical medicine and 
rehabilitation physician's close supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. There are no acute nursing needs identified or 
documented. At the current functional level, the evidence supports that they will not make a significant 
functional recovery in an IRF in a predicted period of 12 days. The lack of medical complexity and lack of 
nursing needs do not support an acute hospital inpatient rehab admission with an interdisciplinary approach to 
rehabilitation care. While they would benefit from therapy services, the enrollee's rehabilitation needs can be 
safely provided in an alternate and low intensity setting such as in an SNF. 
 
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 pre-approve a power tilt and electronic connection for a power 
wheelchair (PWC).  
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 power tilt option 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 enrollee has chronic pain with 
functional deficits. The documentation does not show that you have pressure injuries or require intermittent 
catheterization of the bladder that would necessitate power tilt or recline. The services are 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 power tilt and electronic connection for a power wheelchair (PWC).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endosteal implant (D6010) and the bone graft (D6104) 
provided by a network provider on March 4, 2022. 
 
You asked the Plan to pay for the endosteal implant (D6010) and the bone graft (D6104). You say that this 
should be covered because this was an implant in conjunction with an emergency visit. You say there was no 
other alternative offered other than the implant. The Plan denied your request. The Plan says the services are 
not covered 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 endosteal implant (D6010) and the 
bone graft (D6104) are not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pay for the endosteal implant (D6010) and the bone graft (D6104) provided by a network provider 
on March 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the home ventilator is necessary. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in average volume-assured 
pressure support (AVAPS) mode with Auto-EPAP (AE) that could be delivered by bilevel positive airway 
pressure (BiPAP) is not covered. 
 
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 the home ventilator. Our physician 
reviewer found Medicare does not cover a home ventilator when used as BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a COVID-19 at-home test kit provided on 
December 14, 2021. 
 
You asked the Plan to reimburse you for a COVID-19 at-home test kit. The Plan denied your request. The Plan 
says reimbursement of home COVID-19 tests did not go into effect until February 1, 2022 
 
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 a COVID-19 at-home test kit have not been met. Therefore, we decided that the Plan does not have 
to reimburse you for a COVID-19 at-home test kit provided on December 14, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the non-emergency ambulance services. 
 
You asked the Plan to pre-approve the non-emergency ambulance services. You say that the enrollee has been 
in pain for past days and needs to be seen by a doctor to be examined. You state that the enrollee is an amputee 
and is unable to be in a wheelchair due to their right leg still being fractured. You state a tele-visit is not an 
option because the doctor needs to examine the area in person. The Plan denied your request. The Plan says the 
services are not covered. 
 
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 non-emergency ambulance services have not been met. The 
rules say a doctor's office/clinic is not a covered destination for non-emergency ambulance transportation and 
therefore, not a covered benefit by Medicare. Therefore, we decided that the Plan does not have to pre-approve 
the non-emergency ambulance services.