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

 
We decided that the Plan has to pay for an office visit provided on October 4, 2022. 
 
You asked the Plan to pay for an office visit provided on October 4, 2022. You say that the records attached 
support the services provided. The Plan denied your request. The Plan says that there is no authorization on 
file. 
 
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. No Evidence of Coverage (EOC) was included in the case file Therefore, we 
decided that the Plan has to pay for an office visit  
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve service dog support (S5199) under the special 
supplemental benefit for the chronically ill (SSBCI). 
 
You asked the Plan to pre-approve your service dog. You say that the service should be covered. The Plan 
denied your request. The Plan says the criteria for eligibility have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of your service dog have not been met. Specifically, you have not submitted any supporting 
documentation or medical records indicating you qualify for the SSCI benefit. Therefore, we decided that the 
Plan does not have to pre-approve service dog support (S5199) under the special supplemental benefit for the 
chronically ill (SSBCI).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage (A0170). 
 
You asked the Plan to pre-approve additional mileage. The Plan denied your request. The Plan says you are 
requesting an additional 74 miles for a total of 124 miles, and your benefit only allows 50 miles. The Plan also 
says that you have exceeded your benefit limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles of driving 
distance. 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional mileage (A0170).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96040 billed for date of service September 6, 
2022. 
 
You asked the Plan to pay for procedure code 96040. The Plan denied your request. The Plan says procedure 
code 96040 is considered bundled and not separately payable. 
 
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 96040 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 96040 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
96040 billed for date of service September 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (K0800). 
 
You asked the Plan to pre-approve a power scooter. You say that a power scooter is medically necessary. The 
Plan denied your request. The Plan says that the requested power scooter is not medically necessary. 
 
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.  
 
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 power scooter. Our reviewer says that 
the coverage criteria has not been met. Our physician reviewer found that there is a lack of clinical 
documentation indicating the enrollees level of mobility and ability to transfer. There is also insufficient 
documentation regarding the enrollees physical examination findings, specifically with regards to motor 
strength in both of the upper and lower extremities. There is no indication that the enrollee cannot use a cane or 
walker for assistance with mobility or propel a manual wheelchair. There is also a lack of information as to 
whether the enrollee can safely operate the requested power mobility device and if their home is accessible for 
it. 
 
 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 power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter (K0800).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5298 x 2) purchased on 
October 21, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the items are not payable as they 
were purchased from an unassigned provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased through the Plans select hearing aid provider. Prior authorization must be 
obtained.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met.   
 
Specifically, the Plans contract provides coverage for hearing aids only when purchased through the Plans 
select hearing aid provider. However, the hearing aids in this case were not purchased from an assigned 
provider within the Plans select hearing aid provider network. Additionally, prior authorization was not 
obtained. Therefore, we decided that the Plan does not have to issue reimbursement for the hearing aids  
(V5298 x 2) purchased on October 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation (D0120), and prophylaxis 
(D1110), provided on January 4, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you were never told you had to find an in-
network dentist. The Plan denied your request. The Plan says you are responsible for any charged amount 
above the Plans cost-sharing amount when your services are received from an out-of-network provider. 
 
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 have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to pay more for a periodic oral evaluation (D0120), and 
prophylaxis (D1110), provided on January 4, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on October 25, 2022. 
 
You asked the Plan to pay for laboratory services. You say that you are asking the plan to review the submitted 
medical records and reconsider the denied service for payment. The Plan denied your request. The Plan says 
charges for or in connection with services or supplies that are, as determined by us, considered to be 
experimental or investigational are excluded from coverage under the enrollee's plan. 
 
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 CPT code 85025, 87798, G0471 is not supported in the medical record. Specifically, charges for 
services that are experimental or investigational are excluded from coverage. Based on this information, we 
decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that 
the Plan does not have to pay for laboratory services provided on October 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital services provided from 
November 27, 2022, to November 30, 2022. 
 
You asked the Plan to pay for the inpatient services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the enrollee could have been cared for at an observation level. 
 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 the inpatient services. Our physician 
reviewer found that the enrollee presented with shortness of breath, chest pain, cough and was positive for 
Covid-19. He was treated for acute on chronic congestive heart failure with diuresis, remdesivir, and low dose 
oxygen support. Vitals were stable and the enrollee was responding to treatment appropriate on admission. He 
was not expected to require a prolonged stay and was quickly tolerating oral. It was not expected that he would 
require hospital services that would likely cross 2 midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the inpatient services have not been met. Therefore, we decided that the Plan 
does not have to pay for the acute inpatient hospital services provided from November 27, 2022, to November 
30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you have fractures of the pelvis and back and have 
difficulty moving your arm. You say the IRF services are necessary before you go home. The Plan denied your 
request. The Plan says the requested IRF admission is not medically necessary. 
 
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 complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you may have a need for physical therapy and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. There is not a reasonable expectation 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 an IRF admission and services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for Hematology Profile testing (81455) provided on October 4, 2022. 
 
You asked the Plan to pay for Hematology Profile testing. You say that the enrollee meets criteria for coverage. 
The Plan denied your request. The Plan says that this service is not covered. 
 
The Plan follows Medicare rules. Medicare rules say that this testing is covered when it is medically necessary 
and the criteria for coverage 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 pay for Hematology Profile testing. Our reviewer 
says that this testing was medically necessary. Our physician reviewer found that per the National 
Comprehensive Cancer Network (NCCN) Guidelines for myelodysplastic syndrome (MDS), genetic testing for 
somatic mutations in genes associated with MDS is highly recommended. This can be done on bone marrow or 
peripheral blood both for diagnosis and treatment decision making. The service was reasonable and 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 Hematology Profile testing have been met. Therefore, we decided that the Plan 
has to pay for Hematology Profile testing (81455) provided on October 4, 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital services provided from October 26, 2021, to 
November 8, 2021. 
 
You asked the Plan to pay for the inpatient hospital services. You say that this claim was denied in error. You 
also say that this was not an overlapping stay, as the enrollee was re-admitted on October 26, 2021, not on 
October 25, 2021. The Plan denied your request. The Plan says that the enrollee was re-admitted for symptoms 
related to the prior stay's medical condition. The Plan also says this is not recognized as a separate inpatient 
admission, and payment for these services was included with the reimbursement for the initial hospital stay. 
 
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 records do not support the Plan's denial in this case. Specifically, medical 
records were not provided, nor does it appear they were requested. This means that the Plan has not provided a 
valid reason for denying payment of the inpatient hospital services. It is the burden of the Plan to substantiate 
their denial with evidence. In this case, the denial has not been substantiated so we must find in your favor. 
Therefore, we decided that the Plan has to pay for the inpatient hospital services provided from October 26, 
2021, to November 8, 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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that you are appealing the denied CGM. The Plan denied 
your request. The Plan says that the Medicare criteria was not met. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not collect medical records from their participating 
provider who ordered the requested CGM. Participating providers are considered agents of the Plan. Without 
this necessary documentation we are unable to make a determination as to whether the enrollee has met the 
criteria for coverage of a CGM. Therefore, we decided that the Plan has to pre-approve a continuous glucose 
monitor (CGM).  
 
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 procedure code 99152 billed for date of service December 8, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the documentation supports the billed code. The 
Plan denied your request. The Plan says the code is included in code 45378. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   We looked at the file and the rules. The medical records do not show that the service billed with the -59 
modifier was a distinct procedural service. Furthermore, there is a more suitable code to describe sedation 
during a gastrointestinal endoscopic service. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99152 billed for date of service December 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the percutaneous image guided lumbar decompression 
(PILD) (0275T). 
 
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 records do not support 
that the enrollee meets the Medicare criteria. 
 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 surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the percutaneous image guided lumbar decompression (PILD) 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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the percutaneous image guided lumbar decompression (PILD) (0275T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that you do not have the assistance to go to a store 
or do things for yourself. You say that you would like to be able to be more involved in your community. You 
also say that if you were authorized for a scooter, you would obtain proper storage for it. The Plan denied your 
request. The Plan says the requested power scooter is not medically necessary. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided May 11, 2022, to June 8, 
2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the primary diagnosis billed is not supported as the reason 
for home health. 
 
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 asked our physician 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 home health services as billed. The home health 
services were billed with a primary diagnosis of I10, defined as essential (primary) hypertension. Our reviewer 
says that the documentation does not support the primary diagnosis billed as the reason for home health. Our 
reviewer found the enrollee had stable blood pressure. The records indicate a stable patient with dementia. The blood pressure and medication management were not issues in the care. Skilled nursing visits were not 
necessary to manage blood pressure. There is no evidence of nutrition review and steps necessary to manage 
blood pressure. The diagnosis and the skilled nursing interventions are not congruent and the nursing services 
were not necessary to address blood pressure. 
 
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 home health services as billed have not been met. Therefore, we decided 
that the Plan does not have to pay for the home health services provided May 11, 2022, to June 8, 2022.