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

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
December 7, 2022. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you did not know these 
were out-of-network services. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for out-of-network Medicare-covered physician specialist services.  
 
You have been asked to pay a $35 copayment for the specialist office visit. This item/service falls within the 
physician/practitioner services, including doctor's office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. 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 waive the copayment for the specialist office visit provided on December 7, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sodium ferric gluconate complex in sucrose solution 
12.5mg/ml. 
 
You asked the Plan to pre-approve sodium ferric gluconate complex in sucrose solution 12.5mg/ml. You say 
that the requested drug is medically necessary. The Plan denied your request. The Plan says the prescription is 
missing clinical information to meet the quality and safety criteria for this drug. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers intravenous iron therapy for certain 
conditions. 
 
 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 sodium ferric gluconate complex in 
sucrose solution 12.5mg/ml. Our physician reviewer found that the records indicate the enrollee is a 72-year-
old female whose provider requested ferric glucose for iron deficiency anemia 6.6gr/dl Hgb, Ferritin 10ug, 
Saturation Iron 8.60. The enrollee has a history of hypertension, chronic kidney disease Stage 4, diabetes 
mellitus II, and anemia. There are safety issue concerns in the patient administration of this medication home 
IV due to risk of anaphylactic reactions, hypotension shock, cardiac arrhythmia even can cause the death. The 
review indicates that the enrollee does not meet the coverage indications for this procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sodium ferric gluconate complex in sucrose solution 12.5mg/ml have not been 
met. Therefore, we decided that the Plan does not have to pre-approve sodium ferric gluconate complex in 
sucrose solution 12.5mg/ml.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the enrollee cannot tolerate BiPAP. The Plan 
denied your request. The Plan says the type of support requested can be provided by a BiPAP. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a ventilator. Our physician reviewer 
found that the enrollee has a diagnosis of chronic respiratory failure consequent to chronic obstructive 
pulmonary disease.   
 The home ventilator is being requested for use in average volume-assured pressure support (AVAPS) mode 
with auto-EPAP (AE) which could be provided by a BiPAP device. The provided records do not document trial 
and failure of a BiPAP device with AVAPS and a back-up rate. Ventilators used to provide continuous positive 
airway pressure (CPAP) or bi-level CPAP therapy are not reasonable and 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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crutch and cane holder (E2207). 
 
You asked the Plan to pre-approve a crutch and cane holder. You say that the item is medically necessary. The 
Plan denied your request. The Plan says can and crutch holders are not medically necessary for in home use of 
a wheelchair. 
 
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 crutch and cane holder (E2207).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service December 
12, 2022. 
 

You asked the Plan to pay for procedure code 99100. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service December 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wheelchair repairs to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the wheelchair repairs. You say that the items should be covered. The Plan 
denied your request. The Plan says there are in-network providers available for this service. 
 
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 
the wheelchair repairs to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 69209 provided on July 20, 2022. 
 
You asked the Plan to pay for procedure code 69209. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 We looked at the file and Medicare rules. In this case, the enrollee received services (69209) while in an 
outpatient hospital setting. Per Medicare payment guidelines, code 69209 has a PC/TC indicator of 5 and 
payment may not be made for this code when provided to patients in an outpatient hospital setting. Therefore, 
we decided that the Plan does not have to pay for procedure code 69209 provided on July 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical removal of implant body (D6100) for tooth 
#30. 
 
You asked the Plan to pre-approve the dental service. You say that you are appealing the denied dental service. 
The Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on the date of service of January 30, 2023. 
Therefore, we decided that the Plan does not have to pre-approve the surgical removal of implant body 
(D6100) for tooth #30.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says based on Medicare guidelines, the IRF services 
requested do not meet the requirements for approval. 
 
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 the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee 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 that 
the enrollee 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for July 27, 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 procedure code 99223 is not supported by the medical records. 
 
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 99223 is initial hospital inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded. 
 
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 these services. Our reviewer says that procedure code 99223 is not supported by the medical records. Our reviewer found that the documentation describes the enrollee as 
having a history of prostate cancer on Xtandi, hypertension, insomnia, benign prostatic hyperplasia, and knee 
arthritis. He presented for a right total knee arthroplasty and the date of service at issue is post-operative day 
one. The history was focused and not comprehensive. The physical examination was limited and would not be 
considered comprehensive. Also, the enrollee was stable and the case not complex. There was no decision-
making of high complexity evidenced in the note from July 27, 2022. 
 
We looked at this coder'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 procedure code 99223 billed for July 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 2, 2020, to 
March 9, 2020, 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 the 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed codes. 
 
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 secondary diagnosis codes D62, E43, and J96.01, 
described as acute posthemorrhagic anemia, unspecified severe protein-calorie malnutrition, and acute 
respiratory failure with hypoxia. 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 documentation does not support the billed 
code. Our physician reviewer found that the enrollee is a 70-year-old female who was admitted to the hospital 
for injuries incurred in a motor vehicle accident requiring endotracheal intubation and vent support. Later she 
was extubated and transferred to the acute inpatient rehabilitation facility where she was tolerating room air 
and was not hypoxic or experiencing respiratory distress and was no longer requiring vent support. Therefore, 
the acute respiratory failure with hypoxia (J96.01) diagnosis is not supported. The enrollee was reported to 
have had a stable weight prior to the hospital stay, was eating a regular diet and was gaining weight which does 
not support the code, severe protein-calorie malnutrition (E43). And lastly, the patient had a hemoglobin of 9.6 
during the rehab stay that rose to 11 during the stay. There was no documented active blood loss then or prior 
to this rehab stay to support the code, Acute posthemorrhagic anemia (D62).  
 
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 March 2, 2020, to March 9, 2020, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a colonoscopy and an esophagogastroduodenoscopy 
(EGD) to be performed at the hospital. 
 
You asked the Plan to pre-approve a colonoscopy and an EGD to be performed at the hospital. 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 colonoscopy and an EGD to be 
performed at the hospital. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found available records do not support the 
medical necessity nor reasonableness of an in-hospital standard of care (SOC) for routine performance of an EGD and colonoscopy. Specifically, there is no expectation of a prolonged procedure, of intolerance to 
sedation, nor the presence of significant dysmorphic features nor compromising cardiopulmonary 
comorbidities to warrant the requested in-hospital SOC in lieu of outpatient services. 
 
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 colonoscopy and an EGD to be performed at the hospital have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a colonoscopy and an 
esophagogastroduodenoscopy (EGD) to be performed at the hospital.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the allergy testing to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the allergy testing. You say that you want in-network benefits from this out-
of-network provider. The Plan denied your request. The Plan says there are in-network providers that can 
perform this service. 
 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 
the allergy testing to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Dexcom continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the Dexcom CGM. You say that the item is medically necessary. The Plan 
denied your request. The Plan says only preferred brand products are covered. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. The requested brand is not a preferred brand. Therefore, we decided 
that the Plan does not have to pre-approve the Dexcom continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Obturator/femoral radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve Obturator/femoral RFA. 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 Obturator/femoral RFA. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the clinical value and effectiveness of obturator/femoral radiofrequency ablation in 
the setting of hip pain have not been demonstrated in the peer-reviewed literature. This is considered 
experimental/ investigational. Therefore, the request is deemed not medically reasonable and 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 Obturator/femoral RFA have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Obturator/femoral radiofrequency ablation (RFA).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA test provided on December 9, 2022. 
 
You asked the Plan to pay for the PrismRA test. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says the requested test does not meet requirement for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. The DEX database shows that PrismRA is not covered. Based on this information, we decided that Medicare rules for coverage of the PrismRA test have not been met. Therefore, 
we decided that the Plan does not have to pay for the PrismRA test provided on December 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection. 
 
You asked the Plan to pre-approve SI joint injection. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the documentation does not support moderate/severe low back 
pain over the SI joint or at least 3 positive findings consistent with SI dysfunction. 
 The Plan follows Medicare rules. Medicare rules state that SI joint injections are only covered if certain criteria 
are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SI joint injection. Our reviewer says 
that the enrollee does not meet criteria for this SI joint injection. Our physician reviewer found Medicare rules 
require the documentation of 3 provocative diagnostic tests, but this has not been done. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SI joint injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a sacroiliac (SI) joint injection.