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

 
We decided that the Plan does not have to pay for remote patient monitoring devices provided on  
August 13, 2022. 
 
You asked the Plan to pay for remote patient monitoring devices. The Plan denied your request. The Plan says 
that the Plan requires utilization of network providers when possible and available and requires authorization 
for certain services. No medical necessity for an out-of-network provider such as an urgent or an emergent 
situation that has been documented.   
 
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 pay 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 pay for these services. Therefore, we 
decided that the Plan does not have to pay for remote patient monitoring devices provided on August 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services billed with codes 87798-91 (12 units), 
87481-59, 87640-59, 87651-59, 87653-59, 87496-59, 87500-59, 87511-59, 87529-59, and 87532-59 on 
February 16, 2022. 
 
You asked the Plan to pay for laboratory services. You say that this was medically necessary. The Plan denied 
your request. The Plan says this cannot be paid as billed. 
 The Plan must follow Medicare rules. The rules state that codes 87798, 87481, 87640, 87651, 87653, 87496, 
87511, 87529, and 87532 are not covered for a given beneficiary on the same date of service when more than 
two are billed for the same intended use. The rules state that providers may bill services with a -59 modifier if 
the service billed with the modifier indicates a distinct procedural service.   
 
Twelve units of code 87798 and codes 87481, 87640, 87651, 87653, 87496, 87511, 87529, and 87532 were 
billed for the same date of service for the same use. The medical records provided do not show that code 
87500-59 modifier is a distinct procedural service. Specifically, the record does not indicate it was performed 
in a separate encounter or for a separate indication from the other billed services. 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 billed with codes 87798-91 (12 units), 87481-59, 87640-
59, 87651-59, 87653-59, 87496-59, 87500-59, 87511-59, 87529-59, and 87532-59 on February 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI. You say that the services are medically necessary. The Plan denied 
your request. The Plan says based on the lack of information provided, there is no documentation that the 
member meets the criteria. 
 
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 SSBCI have been met. Therefore, we 
decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair and accessories. 
 
You asked the Plan to pre-approve a wheelchair and accessories. You say that your benefit does not cover 
durable medical equipment provided in a skilled nursing facility. The Plan denied your request. The Plan says 
the enrollee needs this wheelchair. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a wheelchair and accessories is being requested for use in a SNF or hospital. Therefore, we 
decided that the Plan does not have to pre-approve a wheelchair and accessories.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the miscellaneous supply or accessory for use with an 
implanted ventricular assist device (Q0508) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the Driveline stabilization supplies. You say that you are requesting an 
authorization for continuation of services and supplies for review. The Plan denied your request. The Plan says 
enrollees must receive their medical services from an in-network provider with the exception being urgent or 
emergent services. Non-emergent services with non-contracted providers require prior authorization before 
services being rendered. 
 
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 miscellaneous supply or accessory for use with an implanted ventricular assist device (Q0508) 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 a power seat elevation feature (E2300) and an electronic 
connection device (E2311). 
 You asked the Plan to pre-approve the seat lift and electronic connection device. You say that you do not 
believe these items are not covered. The Plan denied your request. The Plan says that a seat lift is not primarily 
medical in nature and an electronic connection device for the power seat elevation feature is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The rules also say that if the sole purpose of an electronic connection device is for the power 
seat elevation feature it will be denied as not covered. 
 
The power seat elevation feature (E2300) does not serve a purpose that is primarily medical in nature. The 
electronic connection device (E2311) is not covered as its sole function is for the power seat elevation feature. 
Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) and an 
electronic connection device (E2311).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on October 4, 
2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this item was issued to the 
patient for use during surgery.  You said that your organization does not receive payment from the facility or 
provider. The Plan denied your request. The Plan says Medicare does not cover devices used in a facility. 
 
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 (or in a facility). Therefore, we decided that 
the Plan does not have to pay for the pneumatic compression device provided on October 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99238 billed for date of service September 
27, 2022. 
 You asked the Plan to pay for procedure code 99238. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says payment for code 99238 is bundled into payment for 
code 99221. 
 
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 99238 
is a column II code to column I code 99221. 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 99238 billed for date of service September 27, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliance (E0657). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that you are 
requesting an appeal regarding the denial of coverage of a Flexitouch pneumatic compression device (E0652) 
and related accessories (E0657) for treatment of the enrollee's head, neck and chest lymphedema. The Plan 
denied your request. The Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema 
pump as there is no failed four-week trial of a basic pneumatic compression device of either E0650 or E0651. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
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, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and segmental pneumatic appliance (E0657).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99220 and 99226 provided on August 17, 
2022, and August 18, 2022. 
 
You asked the Plan to pay for procedure codes 99220 and 99226. You say that the medical records support the 
billing of codes 99220 and 99226. The Plan denied your request. The Plan says the medical records do not 
support the billing of codes 99220 and 99226. 
 
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 99220 is Initial observation care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission to outpatient hospital "observation status" are of high severity. Typically, 70 minutes are spent at the 
bedside and on the patient's hospital floor or unit. The definition of code 99226 is Subsequent observation care, 
per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A 
detailed interval history; A detailed examination; Medical decision making of high complexity. Counseling 
and/or coordination of care with other physicians, other qualified health care professionals, or agencies are 
provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the 
patient is unstable or has developed a significant complication or a significant new problem. Typically, 35 
minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
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 procedure codes 99220 and 99226. Our reviewer says that 
the medical records do not support the billing of codes 99220 and 99226. Our reviewer found for code 99220 
provided on August 17, 2022: The medical records supported a comprehensive history and a comprehensive 
examination. The medical records did not support medical decision making of high complexity. For code 
99226 provided on August 18, 2022: The medical records did not support a detailed interval history. The 
medical records supported a detailed examination. The medical records did not support medical decision 
making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 99220 and 99226 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 99220 and 99226 provided on August 17, 2022, and 
August 18, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the reconstruction of maxilla/mandible with implants, a bone graft, 
and a maxillofacial oral appliance. 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee is unable to chew. The Plan 
denied your request. The Plan says that this dental work is 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 physician 
reviewer found the documentation provided meets the criteria for coverage for the indicated procedures. 
 
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 reconstruction of maxilla/mandible with implants, a bone graft, and a maxillofacial oral 
appliance.  
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you require IRF services to regain maximum 
function and independence. The Plan denied your request. The Plan says the request 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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intensity-modulated radiation therapy (IMRT). 
 
You asked the Plan to pre-approve IMRT services. You say that the requested services are a medical necessity 
for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 IMRT services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the provided case records did not adequately demonstrate the need for IMRT using 
plausible dosimetric evidence (i.e. to what extent IMRT reduced the dose-volume exposure of critical normal 
tissues).  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IMRT services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve IMRT.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) (E0675) and 
appliance (E0673) provided on May 16, 2022. 
 
You asked the Plan to pay for the PCD and appliance. The Plan denied your request. The Plan says this is not 
covered for use outside the home. 
 
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 pay for the pneumatic compression device (PCD) (E0675) and appliance (E0673) provided on May 16, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the peripheral nerve block/pudendal nerve block 
(64430). 
 
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 Medicare rules state that experimental and investigational devices are not 
covered. 
 
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 the enrollee has chronic vaginal pain despite medical therapy and has responded to previous 
pudendal nerve blocks. However, there is not enough evidence to show that this procedure is safe or that it works well for chronic pain. Medicare does not cover pudendal nerve blocks because, per clinical policy, there 
is not enough evidence to show that this procedure is safe and that it works well for chronic pain. Medicare 
rules state that this type of injection is considered experimental/investigational, and effectiveness has not been 
established. The billing code is not supported by medical necessity. 
 
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 the peripheral nerve block/pudendal nerve block (64430).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF is better suited for your rehabilitation needs. 
The Plan denied your request. The Plan says the request 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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need IRF services in order to walk 
independently again. The Plan denied your request. The Plan says the request 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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
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 IRF admission and services.