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

 
We decided that the Plan does not have to pay for the nursing and debridement services rendered on March 24, 
2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the enrollee was on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the nursing and debridement services rendered on March 24, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 29874 and 29877 billed for date of service 
August 17, 2022. 
 
You asked the Plan to pay for procedure codes 29874 and 29877. You say that you disagree with the denial. 
The Plan denied your request. The Plan says payment for codes 29874 and 29877 is bundled into payment for 
codes 29880 and 29875. 
 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, we have confirmed that code 29874 
is a column II code to column I code 29880 and code 29877 is a column II code to column I code 29875. This 
claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, 
Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 29874 and 29877 billed for date of service August 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the automatic external defibrillator, with integrated 
electrocardiogram analysis, garment type (K0606) provided September 7, 2021. 
 
You asked the Plan to pay for the automatic external defibrillator. You say that you are requesting review of 
the medical records attached to show medical necessity and reconsideration of your claim for payment. The 
Plan denied your request. The Plan says the claim was received after the timely filing limitation. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the automatic external defibrillator was not filed until October 3, 2022. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for the automatic external defibrillator, with 
integrated electrocardiogram analysis, garment type (K0606) provided September 7, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 1, 2022, to June 
30, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the NOA was submitted, and the 
claim should be reprocessed for payment. The Plan denied your request. The Plan says the claim has not been 
billed with the correct admission date. 
  The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue and 
the admission date reported on the NOA is incorrect. Based on this information, we find that the Medicare rules 
for payment of the claim at issue have not been met. Therefore, we decided that the Plan does not have to pay 
for the home health services provided from June 1, 2022, to June 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for psychiatric services provided from  
September 30, 2022 to November 9, 2022, by an out-of-network provider. 
 
You asked the Plan to reimburse you for the psychiatric services. You say that you have been reimbursed in the 
past for all the visits with this provider and there should be no reason not to be reimbursed. The Plan denied 
your request. The Plan says you must receive your care from a network provider. In most cases, the care you 
receive from an out-of-network provider will not be covered. 
 
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 reimburse you for care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to reimburse you for these services. 
Therefore, we decided that the Plan does not have to reimburse you for psychiatric services provided from 
September 30, 2022 to November 9, 2022, by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT 
code(s): 22869 and 22870). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not 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 items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertilfex device is experimental. 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 the Vertiflex superion device 
placement surgery (CPT code(s): 22869 and 22870).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the palonosetron hydrochloride (HCl), 25 mcg, (J2469) provided on 
May 20, 2022. 
 
You asked the Plan to pay for palonosetron HCl. You say that the service should be covered. The Plan denied 
your request. The Plan says that this drug is experimental and investigational. 
 
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 file does not support that Plan's denial. The provided 
documentation does not support that this service is experimental in nature. Therefore, we decided that the Plan 
has to pay for the palonosetron hydrochloride (HCl), 25 mcg, (J2469) provided on May 20, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous injection of allogeneic cellular and/or 
tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; 
first level (CPT code 0627T). 
 
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 your request is not medically necessary because there is little evidence in 
the medical literature to suggest that this is an appropriate procedure for the enrollee's back pain. The Plan 
states it is not an accepted standard of medical practice for the diagnosis or treatment of back pain. The Plan 
states the requested injection of allograft (e.g., VIA Disc Matrix) into the intervertebral disc for the treatment of 
degenerative disc disease is considered experimental and investigational. The Plan states additionally the safety 
study looking at this procedure excludes people with facet disease like the enrollee's, described as severe on the 
enrollee's magnetic resonance imaging (MRI). 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found injections of cellular product into the disc is experimental at this time.  
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral 
disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; first level (CPT code 0627T).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right and left cataract eye surgery to be provided by an 
out-of-network (OON) provider at the in-network benefit coverage. 
 
You asked the Plan to pre-approve cataract eye surgery. You say that you disagree with the denial. The Plan 
denied your request. The Plan says as a member of the plan, the enrollee can choose to receive care from out-
of-network providers. However, please note providers that do not contract with the plan are under no obligation 
to treat the enrollee, except in emergency situations. The plan will cover services from either in-network or out-
of-network providers, as long as the services are covered benefits and are medically necessary. However, if the 
enrollee uses an out-of-network provider, his share of the costs for his covered services may be higher. 
 
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 
right and left cataract eye surgery to be provided by an out-of-network (OON) provider at the in-network 
benefit coverage.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental 
pneumatic appliances (E0673) provided Ma y 13, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and appliances. You say that the equipment was 
prescribed by the doctor and was issued to the enrollee for use during their surgery. The Plan denied your 
request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein 
thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) and segmental pneumatic appliances (E0673) provided Ma y 
13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Minuteman device. 
 
You asked the Plan to pre-approve a Minuteman device. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 Minuteman device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the minuteman device 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 a Minuteman device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Minuteman device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care billed with code 99232 for June 
21, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says payment is included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that intra- and post-operative services are included in the 
global surgical package. 
 
We looked at the file and Medicare rules. Procedure code 99232 was related to and billed on the same day as 
minor surgical procedure 21811. Payment for code 99232 is included in the global surgical package. Therefore, 
we decided that the Plan does not have to pay for the subsequent hospital care billed with code 99232 for June 
21, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for physician's services provided on October 9, 2022. 
 
You asked the Plan to pay for the physician's services. You say that the services were billed correctly. The Plan 
denied your request. The Plan says that this procedure is not paid separately. 
 
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 a Medicare rule or a coding rule to 
substantiate their denial. Therefore, we decided that the Plan has to pay for physician's services provided on 
October 9, 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 pre-approve Dronabinol. 
 
You asked the Plan to pre-approve Dronabinol. The Plan denied your request. The Plan says Dronabinol is a 
self-administered drug, and is not covered under the medical benefit. 
 
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 Dronabinol.  
 
  Benefits for Dronabinol 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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says criteria for admission to LTACH have not been met, the 
enrollee's medical needs are being met in the current acute setting. The LTACH would add no additional 
services. 
 
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 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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic CGM. 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that a CGM would be extremely helpful for the 
enrollee, due to being near blind and cannot see well. The Plan denied your request. The Plan says the enrollee 
does 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 the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
therapeutic CGM.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on May 16, 2022, to 
May 18, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that these 
services and diagnoses were reported correctly and are supported as billed. The Plan denied your request. The 
Plan says the DRG submitted on this claim is not supported in the medical records. 
 
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 acute kidney failure with tubular necrosis (N17.0). 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the inpatient hospital services at the DRG 
originally billed. Our reviewer says that this diagnosis is not supported in the medical record. Our physician 
reviewer found that while in the emergency department, the enrollee was noted to be nontoxic appearing and 
had a creatinine of 2.1, a glomerular filtration rate of 30.6 and was administered a 1-liter intravenous fluid 
bolus. The documentation stated that the creatinine level decreased to 1.1 and the enrollee had a glomerular 
filtration rate greater than 60 the following day. The physician documented in the progress notes that the acute 
kidney injury was resolved after given intravenous fluids. Upon discharge, the enrollee had a creatinine of 1.0 
with a glomerular filtration rate of greater than 60. The physician documented that there was no baseline 
creatinine available. In this case, review of the medical record found no evidence of clinical symptoms or 
findings on physical exam consistent with a diagnosis of an acute kidney injury. The review has determined 
that the documentation support acute kidney failure with tubular necrosis (N17.0).  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on May 16, 2022, to May 18, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental 
pneumatic appliances (E0673) provided July 7, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and appliances. You say that the equipment was 
prescribed by the doctor and was issued to the enrollee for use during their surgery. The Plan denied your 
request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein 
thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) and segmental pneumatic appliances (E0673) provided July 
7, 2022.