Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and related 
supplies. 
 
You asked the Plan to pre-approve the CGM and related supplies. You say that you are appealing the denied 
CGM. The Plan denied your request. The Plan says the Medicare criteria was 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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM and 
related supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM) and related supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cleaning (D1110) and bitewing x-rays (D0270) by an 
out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network dental services. You say that this is the only dentist who 
has been able to help you. You say you would like to be approved to go to that out-of-network dentist for two 
cleanings a year and one bitewing x-ray a year. The Plan denied your request. The Plan says dental services 
from an out-of-network provider are not covered by your supplemental 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. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve a cleaning 
(D1110) and bitewing x-rays (D0270) by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
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 you do not require insulin three or more times daily. 
 
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 you do not use insulin with at least 
three daily injections. 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 a continuous glucose 
monitor (CGM).
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 services are necessary for the enrollee to receive 
the care needed. The Plan denied your request. The Plan says the enrollee's current medical status does not 
require intensive physician and nursing oversight. 
 
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 does not require intensive rehabilitation to recover from their 
uncomplicated hip fracture repair. There is no indication for frequent of physiatry oversight. The Medicare 
coverage rules are not met. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76140 billed for date of service September 2, 
2022. 
 
You asked the Plan to pay for procedure code 76140. You say that the claim should be paid. The Plan denied 
your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 76140 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 76140 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 76140 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 76140 billed for date of service September 2, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Intensity Modulated Radiation Therapy (IMRT) (77014, 77386, 
77387). 
 
You asked the Plan to pre-approve IMRT. You say that you disagree with the denial and request 
reconsideration for therapy. The Plan denied your request. The Plan says that the request does not meet the 
Medicare or health plan coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IMRT. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found with IMRT, often full dose can be delivered to the target, while minimizing dose to the normal 
organs. IMRT can be considered necessary when a 3D plan is unacceptable and the IMRT plan results in a 
clinically meaningful reduction in normal tissue dose-volume delivery and/or improved target coverage. For 
this enrollee, the dosimetric comparison shows inadequate target coverage with the 3D plan and the exposure to 
the proximal bronchial tree and spinal canal are excessive.  Better 3D planning with field in field approaches 
could perhaps improve upon these short comings, but with an unacceptable 3D plan, IMRT is generally 
accepted as a standard of care. Conceding that the dose-fractionation for this enrollee is not typically employed 
for Stage II NSCLC, the decision is favorable as IMRT for 6 Gy x 10 is plausibly, and demonstrated with 
planning records, justifiable over 3D as an accepted standard. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IMRT have been met. Therefore, we decided that the Plan has to pre-approve 
Intensity Modulated Radiation Therapy (IMRT) (77014, 77386, 77387).  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One. 
 
You asked the Plan to pre-approve Gel-One. You say that the records provided support the need for the 
requested drug. The Plan denied your request. The Plan says they do not have record from the prescriber that 
shows the enrollee has tried one of the preferred drugs or that they have medical reasons that prevent them 
from using one of the preferred drugs. 
 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 Gel-One. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of drugs 
Monovisc, Orthovisc, Synvisc, or Synvisc One before they will approve the requested drug, Gel-One. There is 
no indication that the enrollee has tried and failed the required drugs. There is no indication that the Plan's 
required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the subsequent hospital care (99232) provided on August 10, 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 that it is not appropriate to report inpatient evaluation and management service and place of 
service 21 when the enrollee's claim history shows that the enrollee was in an outpatient hospital observation 
status for this date of service. 
 
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 did not send a claim to verify that the enrollee was in an outpatient 
hospital observation status for this date of service. The provider submitted an inpatient claim with the correct 
place of service and medical records to verify that the enrollee was inpatient for this date of service. Therefore, 
we decided that the Plan has to pay for the subsequent hospital care (99232) provided on August 10, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medication (J3490) provided on November 17, 2022. 
 
You asked the Plan to pay for the medication. You say that the claim should be paid. The Plan denied your 
request. The Plan says the provider did not bill as required by Medicare coding regulations. 
 
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 medication have not been met. Records indicate surgery 
procedure 64490 has a global surgery value of 000 on the CMS National Physician Fee Schedule (NPFS) 
Relative Value (RVU) file. This is an endoscopy or minor procedure that has a global surgery period of 000 
days. Procedure code J3490, is included when billed within the global surgery period of an endoscopy or minor 
surgery procedure 64493 without an appropriate modifier. Therefore, we decided that the Plan does not have to 
pay for the medication (J3490) provided on November 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the records provided support the need 
for the requested procedure. The Plan denied your request. The Plan says medical studies have not proven that 
this service is helpful for the treatment of the enrollee's health problem. 
 
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 Intracept procedure. Our reviewer 
says that the Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental. More research is needed. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided to the enrollee from April 6, 2021, 
to May 19, 2021. 
 
You asked the Plan to pay for the services. You say that there was supporting documentation submitted for 
reconsideration of the adjustment. The Plan denied your request. The Plan says that the charges were 
appropriately denied. 
 
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. That our reviewer looked at the itemized charges, and found that the plan did not 
include enough information to confirm the denied charges of $10,516.16 for denial code G and $8.738.62 for 
denial code F. The itemized bill does not specify which services are code G and code F. The plan has not 
substantiated their denial. Therefore, we decided that the Plan has to pay for inpatient hospital services 
provided to the enrollee from April 6, 2021, to May 19, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office or other outpatient visit for the evaluation and 
management of an established patient (99212) provided on May 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 there is a mismatch in the service provided and the place of service (POS) 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. 
 
In this case, the CPT Code Manual definition of code 9912 is office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination 
and straightforward medical decision making. When using time for code selection, 10-19 minutes of total time 
is spent on the date of the encounter. 
 
We find that CPT code 99212 is not supported in the medical record. Specifically, an inpatient hospital POS 
(21) was billed with an office or other outpatient visit (99212). There are more appropriate codes to be used 
when the POS is 21. Based on this information, we decided that Medicare rules for coverage of the service 
have not been met. Therefore, we decided that the Plan does not have to pay for the office or other outpatient 
visit for the evaluation and management of an established patient (99212) provided on May 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist 
device (L8702). 
 
You asked the Plan to pre-approve a MyoPro orthotic device. You say that the device is medically necessary. 
The Plan denied your request. The Plan says although the requested device is reported as having some utility in 
post-stroke rehabilitation in terms of facilitating recovery, it is not considered the standard of care. Further 
research is needed to determine whether this device offers a clinically significant benefit in comparison with 
conventional treatments. 
 
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 a MyoPro orthotic device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the MyoPro Orthosis is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes. The MyoPro is not the standard of 
care for this enrollee's condition or in widespread use for this enrollee's condition based on scientific evidence. 
There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes 
for this enrollee. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a MyoPro orthotic device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a powered upper extremity range of motion assist device (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office or other outpatient visit for the evaluation and 
management of an established patient (99212) provided on April 19, 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 there is a mismatch in the service provided and the place of service (POS) 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. 
 
In this case, the CPT Code Manual definition of code 99212 is office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination 
and straightforward medical decision making. When using time for code selection, 10-19 minutes of total time 
is spent on the date of the encounter. 
 
We find that CPT code 99212 is not supported in the medical record. Specifically, an inpatient hospital POS 
(21) was billed with an office or other outpatient visit (99212). There are more appropriate codes to be used 
when the POS is 21. Based on this information, we decided that Medicare rules for coverage of the service 
have not been met. Therefore, we decided that the Plan does not have to pay for the office or other outpatient 
visit for the evaluation and management of an established patient (99212) provided on April 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from October 24, 2021 to 
November 20, 2021. 
 
You asked the Plan to pay for the services. You say that you submitted supporting documentation for 
reconsideration of DRG adjustment. The Plan denied your request. The Plan says the itemized bill summary 
shows that several services should not have been unbundled. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 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 a review of the items billed with 
denial code G showed that they denied correctly, as the services are routine supplies and would be included in 
the critical care setting. A review of the items billed with denial code G shows that they were denied correctly, 
as documentation to support the billed service "Dressing, Large Sacrum" was not found in the documentation. 
In terms of the "intubation, endotracheal" denied with code H, these charges have been credited and would not 
be eligible for additional reimbursement. 
 
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 inpatient hospital services rendered from October 24, 2021 to November 20, 2021.