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

 
We decided that the Plan does not have to pre-approve a pneumatic compression device and other accessories. 
 
You asked the Plan to pre-approve the DME. You say that you are having surgery and need the DME as soon 
as possible. The Plan denied your request. The Plan says the DME is not covered by Medicare or the Health 
Plan. 
 
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 pre-approve a pneumatic 
compression device and other accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the all-terrain Group 4 power wheelchair.  
 
You asked the Plan to pre-approve the power wheelchair. You say that you are requesting an appeal because 
your chair is replacement and there are some days where your physical limitations have caused your power 
wheelchair to be unstable and have caused injury. The Plan denied your request. The Plan says A power 
wheelchair that is miscoded and used for outside the home cannot be approved. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that the requested Trackmaster was designed as an all-terrain power chair and is not intended 
for home use. This is an all-terrain powerchair that is used for outside the home. This means that Medicare 
rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-
approve the all-terrain Group 4 power wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 22, 
2021, through October 25, 2021. 
 
You asked the Plan to pay for these services. You say that the acute inpatient hospital care provided was 
medically necessary for the enrollee. The Plan denied your request. The Plan says the acute inpatient hospital 
care provided 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 these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that this enrollee with dementia was admitted to the hospital and treated for a urinary tract 
infection, dehydration, and was treated with intravenous fluids and antibiotics. She refused to eat or drink 
which was why she was admitted. The workup was otherwise essentially unremarkable. Her vital signs were 
stable following initial treatment in the emergency department (ED). She was later discharged on oral 
antibiotics. A request was made for payment of the inpatient hospital care provided from October 22, 2021, 
through October 25, 2021. The provided records reveal the enrollee as not in a complex or severe clinical 
situation that would warrant inpatient services that were expected to cross 2 midnights as she only required 
observation, continued fluids and antibiotics, and pushes to eat and drink more which could be completed at an 
observation level for a short duration.  
 
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 pay for the acute inpatient hospital care provided from October 22, 2021, through October 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (ESI) (62323). 
 
You asked the Plan to pre-approve a repeat ESI. You say that a repeat injection is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested repeat injection is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat epidural steroid injection (ESI) is medically 
necessary when the first injection directly and significantly provided at least 50% pain relief for at least three 
months. 
 
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 repeat ESI. Our reviewer says that the 
requested repeat ESI is not medically necessary. Our physician reviewer found the provided documentation 
does not indicate that the enrollee had 50% pain relief for three months after the initial ESI. Therefore, the 
reviewer found that a repeat ESI is not 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 a repeat ESI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat epidural steroid injection (ESI) (62323).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 70544 and 70546 billed for date of service 
September 5, 2022. 
 You asked the Plan to pay for procedure codes 70544 and 70546. You say that the enrollee had multiple exams 
on the date in question. The Plan denied your request. The Plan says payment for codes 70544 and 70546 is 
bundled into payment for code 70553. 
 
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 codes 
70544 and 70546 are both column II codes to column I code 70553. 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 70544 and 70546 billed for 
date of service September 5, 2022.
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 you prefer to admit to an acute rehab because you 
were independent and active before coming to the hospital and wish to return to being independent as quickly 
as possible. You are eager to participate and complete the required 3 hours of therapy and unfortunately will 
not get that in a nursing home setting. The goal is to return home within the next 7-10 days, and 
you are fearful that this will not happen if go to a nursing home. Your physician states that you can receive 
medical management of my current needs and can be seen daily by a physician at rehab and reduce the risk of 
returning to the hospital The Plan denied your request. The Plan says admission to an acute inpatient 
rehabilitation facility cannot be covered for the enrollee per Medicare rules. The notes do not show that the care 
specifically requires the involvement of a doctor in the field of Rehabilitation Medicine. The notes do not show 
that the enrollee has complex care needs that require a coordinated team approach and do not show they must 
have an intensive therapy program (3 hours a day, at least 5 days a week) to improve self-care functioning. The 
medical and therapy needs could be met safely in a skilled nursing unit.  
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 you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided safely in a different level of care. There is not a reasonable 
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF. 
 
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: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure codes 99214, 97810, 97814, G0283, 97140 and 97016. We 
decided that the Plan does not have to pay for procedure codes 97010 and 97026.  
 
You asked the Plan to pay for outpatient therapy services (97010, 97026, 99214, 97810, 97814, G0283, 97140 
and 97016) provided on October 1, 2021. You say that these services were medically necessary and are 
supported in the medical record. The Plan says that the payment for code 97010 is always bundled into the 
payment for other services and is not separately payable. Procedure code 97026 is for infrared therapy services, 
which is not covered by Medicare. 
 
We decided that the Plan has to pay for procedure codes 99214, 97810, 97814, G0283, 97140 and 97016.  
 
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 any reason that these codes would be 
denied, nor did the Plan provide a valid reason that the code, or codes, are exempt from the Medicare Managed 
Care Reconsideration appeal process. Therefore, we decided that the Plan has to pay for procedure codes 
99214, 97810, 97814, G0283, 97140 and 97016.  
 
We also decided that the Plan does not have to pay for procedure codes 97010 and 97026. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. The rules say that there are no covered 
indications for infrared light therapy. 
 
We find that procedure code 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. In addition, code 97026 is for infrared light therapy, which is 
not covered for any indication. Based on this information, we decided that Medicare rules for coverage of 
procedure codes 97010 and 97026 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure codes 97010 and 97026. 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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that the services requested are medically 
necessary. The Plan denied your request. The Plan says that the services requested are not medically necessary. 
 
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. The Plan covers the dental 
services when the services are medically necessary and reasonable. 
 
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 dental services. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the documentation provided meets 
the criteria for coverage for a core buildup (D2950) and crown restoration (D2740) for tooth #3. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have been met. Therefore, we decided that the Plan has to 
pre-approve the dental services.  
 
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 fluid circulating cold pad with pump (E0218) and a 
cold or hot fluid bottle (A9273). 
 
You asked the Plan to pre-approve a fluid circulating cold pad with pump and a cold or hot fluid bottle. You 
say that you are having knee replacement surgery and the ice machine will be crucial in your rehab from 
surgery. The Plan denied your request. The Plan says the requested items are not covered by the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The LD confirms that the requested items are not covered by the 
Plan. Based on this information, we decided that Medicare rules for coverage of a fluid circulating cold pad 
with pump and a cold or hot fluid bottle have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a fluid circulating cold pad with pump (E0218) and a cold or hot fluid bottle (A9273).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hyperbaric oxygen therapy provided on July 13, 2022, and 
August 26, 2022. 
 You asked the Plan to pay for hyperbaric oxygen therapy. You say that the hyperbaric oxygen therapy was 
medically necessary. The Plan denied your request. The Plan says the hyperbaric oxygen therapy does not meet 
the Medicare coverage guidelines. 
 
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 hyperbaric oxygen therapy have not been met. Therefore, we decided that the Plan does not have to 
pay for hyperbaric oxygen therapy provided on July 13, 2022, and August 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CGM and related supplies. 
 
You asked the Plan to pre-approve a CGM and related supplies. You say that the requested items are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage of CGMs and related 
supplies have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The 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 a 
CGM and related supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a CGM and related supplies.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says that the admission to a SNF is not medically necessary. 
 
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 pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you have made slow progress with therapy, there is no indication that 
transferring to a skilled nursing facility is required. You can continue to receive skilled rehabilitation services 
at the current inpatient rehabilitation facility or be stepped down to a lower level of care when appropriate. 
There are no services offered at a SNF that are not offered at an inpatient rehabilitation facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service August 11, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
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 76705 
is a column II code to column I code 93976. 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 code 76705 billed for date of service August 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of excessive skin and subcutaneous tissue of 
the thigh (15832). 
 
You asked the Plan to pre-approve the surgical procedure. You say that the medical records provided support 
the necessity of the services in dispute. The Plan denied your request. The Plan says the requested surgery to 
remove extra skin from your thighs is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the surgical procedure have been met. 
additional records were requested from the provider. The records show that the Plan made multiple attempts to 
obtain the needed records without success. Therefore, we decided that the Plan does not have to pre-approve 
removal of excessive skin and subcutaneous tissue of the thigh (15832).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapy services (97110) provided on December 8, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that payment for CPT code 97110 is not supported in the medical record. Specifically, it is 
inappropriate to bill code 97110 for home therapy services. There is a more appropriate code for the services 
provided in this case. 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 the therapy services (97110) 
provided on December 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous spacer placement (22869, 22870, 
C1821). 
 
You asked the Plan to pre-approve the interspinous spacer placement. You say that this service is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has 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 the interspinous spacer placement. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found current evidence based medical guidelines and peer reviewed literature do not 
fully support the spinal decompression device procedure over lumbar laminectomy. More research is needed to 
show safety and efficacy. 
 
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 interspinous spacer placement have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an interspinous spacer placement (22869, 22870, C1821).